cms_HI
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2017-10-20 | 280 | D | 0 | 1 | 5D9Q11 | Based on observations, staff interviews and electronic medical record (EMR) reviews, the facility failed to ensure that 1 of 16 residents (R #10) was consulted on personal preferences. Findings include: On 10/18/2017 at 2:19 PM R#10 was observed sleeping in bed. Staff #2 explained that staff were alert to resident's coughing as signal that assistance is needed and R#10 didn't want to use the soft call-light because often inadvertently triggered the call light by his/her head movements. Reviewed the resident's Care Plan (CP) which states Potential for Decrease in ADL, that interventions dated 8/24/15 included: I am to use a soft touch call light to call for assistance which is to be placed by my pillow near to my face. I will turn my head/face to touch the call bell. Discussed with Staff #2, that intervention of soft call-light still on ADL CP and there was no intervention that staff should listen for the resident's coughing as signal for assistance. Staff #2 went to ask R#10 if he/she wanted a soft call-light and R#10 responded, yes by nodding his/her head. The resident's sister came to visit at that time and Staff #2 explained to her that R#10 now wanted to use the soft call-light. Staff #2 called for the soft call-light to be re-installed. The facility did not explore care alternatives through a thorough care planning process in which the resident could participate. | 2020-09-01 |
| 2 | 2 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2017-10-20 | 314 | D | 0 | 1 | 5D9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and Electronic Medical Record (EMR) reviews, the facility failed to ensure that 1 of 16 residents (R #31) on the Stage 2 Sample Resident List was provided care to promote healing, pain control and prevent infection due to an existing pressure ulcer (PU). Finding include: During an EMR review on 10/17/2017 at 08:31 AM R #31 was admitted with a Stage 4 pressure ulcer to the right buttock and hip. There were no orders for wound vac dressing changes three times per week (Monday, Wednesday and Friday). During an interview on 10/18/2017 at 11:04 AM, Staff #2 stated that staff nurses do the daily wound care which includes the wound vac dressing changes. The wound nurse does weekly assessments once per week. Queried where wound nurse documentation would be located and Staff #2 looked at EMR under Notes but there was no wound nurse documentation for the once a week evaluation. Staff #2 explained that if wound healing, wound nurse wouldn't document because wound healing nicely. Pointed out documentation by Staff #47 written on 10/05/17 at 11:27 in Nurse Note, wound Right butt: no overall improvement noted in R butt wound status. Per Staff #52, (Wound Nurse), obtain surgical consult for R butt wound. Documentation of the EMR revealed inconsistent information regarding the wound characteristics. The wound measurement flowsheet stated the wound had undermining which was at 2 cm; the wound length got larger. Staff #2 stated the inconsistency is probably due to different nurses measuring the wound. Staff #2 further stated that goals were the same, maintain granulation tissue and get closer to surface then outside start to shrink. There was no infection, no redness or warmth around and no slough. Staff #47 documented odiferous on 10/16 and wound nurses both noted wound not odiferous during dressing change. On 10/19/2017 at 9:22 AM observed Wound nurses Staff #52 and #53 do dressing change to R #31's R buttock pressure … | 2020-09-01 |
| 3 | 3 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2017-10-20 | 371 | F | 0 | 1 | 5D9Q11 | Based on observations and staff interviews the facility failed to ensure that residents eating utensils and food preparation dishes were being properly sanitized. Findings include: On 10/16/2017 at 10:19 AM during the initial kitchen tour, the dishwashing machine temperature log for (MONTH) documented temperatures for final rinse cycle were out of range and did not reach 180 degrees Fahrenheit for the final rinse cycle. According to Staff #54, when the staff take temperature and its wrong, it should be checked again. The procedure that the kitchen staff is to follow, is to attach a temperature strip to a coffee mug and run it through the dishwashing machine again. The temperature strip should have been attached to the log with low temperatures to show the correct temperature. During an interview, Staff #54 stated that the dishwasher was broken since (MONTH) and the final rinse temperature was not reaching 180 degrees Fahrenheit. The facility had called the Hobart representative in (MONTH) and was waiting to replace a part. On 10/17/2017 Staff #54 reported that the dishwasher repair was scheduled for 10/19/2017. The facility did not follow proper sanitation of the dishes, eating utensils and cookware to prevent the outbreak of foodborne illness. | 2020-09-01 |
| 4 | 4 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2018-11-16 | 578 | D | 0 | 1 | HKBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the resident with the provisions to formulate an advance directives for two residents (R)7 and R20 of 16 residents reviewed. This includes a written description of the facility's policies to implement advance directives and applicable State law. The residents record lacked documentation stating there was follow up to formulate the advanced directive. Findings include: 1. During the initial record review of R 7' s' electronic medical record (EMR) on 11/14/18 at 01:04 PM no advanced healthcare directives were found. 2. During the initial record review of R20's EMR, no advanced healthcare directives were found. During an interview with the Director of Nursing (DON) on 11/15/18 at 03:30 PM requested a copy of the advanced healthcare directives for both R7 and R20 and was provided only a copy of R20's physician's orders [REDACTED]. The policy on advanced directives/ POLST last revised 08/2018 was reviewed and stated .The POLST form is used by East Hawaii . Newly admitted residents may provide the facility with a previously completed copy of an Advanced Health Care Directives form (AD). The AD will be utilized for Legal Authorized Representative designation. H. If resident does not have an Advanced Health Care Directives and/ or POLST completed, staff will offer assistance in completing a POLST . During an interview with the Administrator on 11/16/18 at 9:47 who stated that the advanced healthcare directives used to be in place until a few years ago when we did away with them and started to formulate and require the POLST. While the POLST is a physician's orders [REDACTED]. | 2020-09-01 |
| 5 | 5 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2018-11-16 | 600 | G | 0 | 1 | HKBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review facility failed to protect resident's right to be free from any type of abuse that results in, or had the likelihood to result in physical harm, verbal abuse, or mental anguish in four Resident's (R) 10, R20, R22, and R30 in the sample of 16. The facility failed to provide care planning interventions and supervision to prevent three incidents involving R30. An incident on 08/09/2018 resulted in R22 striking R30 after verbal confrontation with R30. On 11/04/2018, R30 and R20 had an abusive verbal confrontation that required staff to render a show of force to prevent a physical confrontation. On 11/12/2018, R10 was involved in a verbal confrontation with R30, when he felt R30 was loud and rude to staff. This deficient practice caused harm for R30 resulted in high potential to endanger the other 24 residents residing in the extended care facilitl section. Findings Include: During initial screening of residents on 11/13/2018, R25 expressed she would like to discuss concerns about R30. During a brief interview on 11/14/2018 at 10:50 AM, R25 stated, R30 upset the blind man (R22) to the point he went after him. He is verbally obnoxious. I give the staff credit as they are kind to him. During an interview with resident council members (R10, R22, R25, and R29) on 11/14/2018 at 10:45 AM R22 stated. There's a guy (R30) here who I got into it with. He talks all the time and goes on and on. A couple of months ago I was in the same room and got sick of it and punched him. R10 stated, He is bad to the staff how he talks to them and obnoxious. R29 stated, He was kicked out of bingo and has to know everything about everyone's business. R10 said, He has no respect for women. R25 stated, He (R30) asks one of the CNA's if she'll marry him. She told him she was married, and he tells her to divorce and marry me. When asked if the resident's present felt safe, they replied yes. R10 stated, He's not safe in our environmen… | 2020-09-01 |
| 6 | 6 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2018-11-16 | 726 | D | 0 | 1 | HKBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly date a Peripherally Inserted Central Catheter (PICC) line sterile transparent dressing (dressing) for R135. As a result of this deficient practice, the facility put R135 at risk for infection and/or other PICC line complications. Findings Include: During an observation of a PICC line for R135 on 11/13/18 at 12:30 PM, it was noted that the dressing was not dated. During staff interview with RN57 on 11/13/18 at 12:31 PM, RN57 acknowledged that the PICC line dressing was not dated and should have been. RN57 then stated that the PICC line would be immediately assessed and dressing would be changed and dated. A review of facility policy on Vascular Access Devices; PICCs, Appendix G; PICC, Site Care and Dressing Change stated Central PICC dressing change is a sterile procedure needing dressing kit. BioPatch and [MEDICATION NAME]. A sterile transparent dressing of appropriate size shall be used and changed every 7 days and PRN along with BioPatch and [MEDICATION NAME]. | 2020-09-01 |
| 7 | 7 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2018-11-16 | 761 | D | 0 | 1 | HKBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly discard two medications that were stored in the Lehua Unit Medication Storage Cart. As a result of this deficient practice, two residents (Resident (R) 2, and R6) were at risk of being given an expired medication. Findings Include: 1. During an observation of the Lehua Unit Medication Storage Cart on [DATE] at 09:45 AM, an expired medication bottle of [MEDICATION NAME] was revealed in the storage drawer. This medication belonged to R6, and the label read [MEDICATION NAME] 160 mg/5 ml [MEDICATION NAME], discard after ,[DATE]. 2. During an observation of the Lehua Unit Medication Storage Cart, on [DATE] at 09:46 AM, an expired medication [MEDICATION NAME] was revealed in the storage drawer. This medication belonged to R2, and the label read [MEDICATION NAME] Oral Suspension 40 mg/5 ml, discard after [DATE]. On [DATE] at 09:45 AM, RN57 acknowledged that both medications were expired and should have been removed. According to facility policy on Outdated and Unusable Drugs, it stated All outdated drugs, contaminated drugs shall be returned to the Pharmacy Department for proper disposal. | 2020-09-01 |
| 8 | 8 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2018-11-16 | 812 | E | 0 | 1 | HKBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to monitor temperatures to ensure the refrigerators/freezer were in good working condition, and stored food beyond safe use by dates, in two kitchen refrigerators, one resident nourishment refrigerator, and a storage cabinet on the Long-term care unit. The deficiency compromised food safety for the residents. Findings Include: On [DATE] at 10:20 AM, during an interview with the Food Service Manager (FSM), the monthly refrigerator/freezer temperature logs were reviewed that revealed incomplete documentation of temperature monitoring. The FSM stated, They are to check them twice a day and document on the log. There was no evidence the kitchen storeroom refrigerator, or kitchen storeroom freezer temperature was monitored 12 out of 31 days in August, (YEAR). The log revealed the kitchen GC 14 Refer (Juices) refrigerator was not monitored 13 out of 31 days in August, (YEAR). Temperature documented on [DATE], [DATE], [DATE], and [DATE] was 52 degrees Fahrenheit (F), outside the safe range (41 degrees F, or less) for refrigeration with no evidence of corrective action taken after the deviation was noted. On [DATE], staff entered the comment, couldn't find thermometer. On [DATE] at 10:30 AM identified one container of tofu, and one container of sliced apples in a kitchen refrigerator with expired dates on the labels. The FSM confirmed the food, Needed to be thrown out. On [DATE] at 11:38 AM, inspection of the Long-term care nourishment room revealed one opened container of orange juice and a bowl of crystal light jello stored in the refrigerator with use by dates on the labels that had expired. In addition, there were eight unopened lemon water containers and two unopened orange juice containers stored in the cabinet that were beyond the use by dates. | 2020-09-01 |
| 9 | 9 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2018-11-16 | 842 | D | 0 | 1 | HKBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to accurately document the dates on a Physician Orders for Life-Sustaining Treatment (POLST) form for Resident (R) 23. As a result of this deficient practice, the POLST form would be invalid, and R23 may not have received the care as indicated on the prepared POLST form. Findings Include: During record review for R23, it was noted that the POLST form did not contain the two dates that was required on the form. These two dates were: 1. Date form prepared, and 2. Date of Physician Signature. The POLST form also stated Any section not completed implies full treatment for [REDACTED]. During staff interview with RN52 on 11/16/18 at 09:39 AM, RN52 acknowledged that the POLST form was not complete and missing the required dates. RN52 then stated that the issue would be followed up and presented to the physician. A review of the facility policy on Medical Record Documentation stated Each documentation entry or documents with multiple sections completed by multiple individuals in the medical record shall be immediately dated, timed and signed by the authorized personnel . | 2020-09-01 |
| 10 | 10 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 640 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure a discharge assessment was transmitted within 14 days of completion. Findings include: On 12/19/19 at 11:46 AM, a record review was done for Resident (R)1. R1 was admitted to the facility on [DATE] from an acute hospital. On 07/18/19, R1 was discharged to the community. On 12/19/19 at 11:42 AM, the transmission receipt for R1's discharge assessment was requested of the Resident Assessment Coordinator (RAC). At 12:47 PM, the RAC reported the resident's assessment was batched with other resident's assessments and upon review of the transmission report confirmed R1's discharge assessment was not successfully transmitted. | 2020-09-01 |
| 11 | 11 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 684 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff member, the facility failed to provide a bowel regimen for a resident to address constipation related to the routine and pro re nata (prn) use of opioid medication for pain management for 1 (Resident 18) of 1 residents sampled. Findings include: On 12/17/19 at 02:07 PM, an interview was conducted with Resident (R)18. R18 was asked whether he/she has constipation, R18 responded that he/she takes pain medication which results in constipation. R18 confirmed that sometimes he/she will go without a bowel movement for more than three days. Initially, R18 reported that he/she fixes it on his/her own; however, later reported that medication is provided. On 12/18/19 at 02:58 PM, a record review was done. R18 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the annual Minimum Data Set with assessment reference date of 10/28/19 documents R18 yielded a score of 15 (cognitively intact) upon administration of the Brief Interview for Mental Status. R18 requires extensive assist with one personal physical assist for toilet use. The resident is continent of bowel and bladder. R18 was not coded for constipation. In the medication section, R18 was documented as receiving opioid medications for pain daily in the last seven days. A review of the physician's orders [REDACTED]. every morning; [MEDICATION NAME] powder, 17 gm every 48 hours as needed for constipation with a start date of 10/16/19; [MEDICATION NAME] HCI, 5 mg every four hours for pain, prn; [MEDICATION NAME] HCI, 10 mg every four hours for pain, prn; and routine [MEDICATION NAME] HCI 10 mg. twice a day at 08:00 AM and 05:00 PM. Further review of the facility's intake and output log found the tracking in the electronic health record (EHR) which documents the following: continent of bowel movement (#); incontinent of bowel movement (#); and bowel movements (#). The EHR documents R18 did not have bowe… | 2020-09-01 |
| 12 | 12 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 686 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure prevention of an avoidable facility-acquired pressure ulcer. Although the facility was conducting weekly skin assessments, the assessments did not identify skin issues prior to the emergence of a Stage 2 pressure ulcer to the coccyx. Also, the facility identified an abrasion to the right lateral knee as a result of a mechanical device, the interventions provided did not prevent the abrasion from progressing to a Stage 2 pressure ulcer. Findings include: On 12/18/19, a review of the facility's Resident Census and Conditions of Residents (CMS-672) found documentation of one resident with pressure ulcer (excluding Stage 1). The Facility Matrix provided by the facility on the morning of 12/17/19 did not document Resident (R)2 has pressure ulcer. R2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation of the resident during the initial tour of the facility on 12/17/19 found R2 asleep in bed with noted right below knee amputation. On 12/20/19 at 07:57 AM, a record review was done. A review of the physician's orders [REDACTED]. R2 has a care plan to maintain skin integrity, prevent skin breakdown. The following care plan revisions include: 11/07/19 - monitor for presence of [MEDICAL CONDITION]; 11/25/19 - use skin sleeves to bilateral arms for skin protection and do treatment to my right lateral knee; 12/09/19 - turn me very hour when in bed, continue to do skin check routinely, and notify physician/wound nurse of significant findings; and 12/09/19 - continue to encourage to increase fluid intake as tolerated and if not indicated. On 12/20/19, observation at 09:40 AM found R2 asleep in bed (air mattress), the resident was placed on his/her back with legs raised behind the knees. At 10:10 AM, resident was observed in bed, in the same position. The hospice worker was visiting the resident. A request was made for documentation of skin assessments… | 2020-09-01 |
| 13 | 13 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 725 | D | 0 | 1 | P3CE11 | Based on interviews with residents, the facility failed to ensure the provision of sufficient nursing staff to provide services to assure residents maintain their highest practicable physical and psychosocial well-being. Findings include: 1) On 12/18/19 at 10:00 AM, a confidential interview was done with ten resident council representatives that were invited to participate by the facility staff. The representatives reported staff members will respond to their call light right away; however, they are told they have to wait five to ten minutes as the staff member is providing care for another resident. Three residents reported there has been occasion where they had to wait for 30 minutes. One resident reported this usually occurs during the night shift. And another resident commented that he/she doesn't want to ask for help during the shift change. 2) On 12/17/19 at 01:55 PM, a confidential interview was done with a cognizant resident (the resident yielded a score of 15 on the Brief Interview for Mental Status, which indicates the resident is cognitively intact). The resident reported there are three shifts and identified the 03:00 PM to 11:00 PM as not having enough staff members to provide care. The resident shared that the call light is pressed, the staff member responds, turns off the light, tells you they are busy and will come back. The resident further reported, the call light is being pressed for assistance for repositioning, bathroom and transferring in and out of bed; however, acknowledged that the staff members are run down. | 2020-09-01 |
| 14 | 14 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 726 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to provide nursing professional standard of care for Resident (R)89's peripherally inserted central catheter (PICC). As a result of this deficiency, there is a potential risk for infection. Findings include: Resident (R)89, admitted on [DATE], was receiving intravenous (IV) antibiotic ([MEDICATION NAME] tazobactam) through a peripherally inserted central catheter (PICC). On 12/17/19 at 11:44 AM, licensed nurse (LN)5 prepared to administer intravenous medication for Resident (R)89. Observed the PICC dressing was not labeled, documenting the date, time, and staff that last changed the PICC dressing. LN5 confirmed the PICC dressing should have been labeled with the date, time, and staff initials. Additionally, LN5 confirmed there was no documentation in R89's medical record of the last date the PICC dressing was changed. | 2020-09-01 |
| 15 | 15 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 761 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to discard an expired medication on 1 of 3 medication carts. Findings include: On [DATE] at 12:55 PM, an inspection of the medication cart was done with Licensed Nurse (LN)6. The observation found one bottle of polyethylene [MEDICATION NAME] which was not labeled with an open date. LN6 found the pharmacy label which documented an expiry date of ,[DATE]. The licensed nurse reported this medication will be discarded. | 2020-09-01 |
| 16 | 16 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 812 | F | 0 | 1 | P3CE11 | Based on observations, staff interview, and review of records, the facility failed to 1. Maintain a safe refrigerated food storage, and 2. Maintain water temperature records for the manual dishwashing station. Findings Include: 1. During an initial tour of the kitchen on 12/17/19 at 09:50 AM, the walk-in refrigerator (GC14) was noted to have employee food stored on one of the shelves. The stored food was not labeled, not dated, and not being monitored. The Food Service Manager (FSM), who accompanied the initial tour, was queried about the stored food and acknowledged that the food was not labeled, not dated, and not being monitored. 2. During a follow up visit to the kitchen on 12/19/19 at 09:59 AM, FSM stated that their dishwashing machine had recently broken down and they were manually washing all the dishes. FSM explained the details of their manual washing process. However, upon review of records the facility had not recorded and/or maintained the water temperature for their washing since they started the manual washing process. On 12/19/19 at 11:00 AM, the FSM acknowledged that the facility had not recorded and/or maintained the water temperature for their manual washing process as previously mentioned. FSM actually created a new updated manual washing log which included the missing washing temperatures. | 2020-09-01 |
| 17 | 17 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 880 | D | 0 | 1 | P3CE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to maintain a sanitary environment and failed to prevent the development and transmission of communicable diseases and infections as evidenced by the following: canister of [MEDICATION NAME] powder had a plastic measured cup (scoop cup) that was stored in the powder for multiple use; and a pad on the shower gurney had multiple tears and cracks, resulting in permeability of the plastic covering and allowing liquids/fluids to seep into the padding and resurface when weight is applied. Findings Include: 1) On 12/20/19 at 09:47 AM, during an observation of the medication cart on the North Wing, a 6-8 ounce canister of [MEDICATION NAME] powder was noted to have the scoop cup stored in the powder. Registered Nurse (RN) 23, who accompanied this observation, was asked about the scoop cup. RN23 stated that multiple hands would grab the scoop cup, but there was no procedure to ensure the cup was either sanitized or any procedure to prevent the spread of infections. RN23 further stated that the facility had most recently been using single use packets and wasn't sure when they switched to using the canister. 2) On 12/18/19 at 11:45 AM, observation of the shower room was done with Certified Nurse Aide (CNA)8. The observation found a shower gurney with a blue padding insert. The blue pad had cracks in the raised area under the head and around the drainage holes. Inquired how is the pad sanitized, CNA8 responded the pad is washed down after use and sprayed with a sanitizing solution. Initially CNA8 stated the residents are placed directly on the plastic padding; however, after discussion that the plastic covering was now permeable, the CNA reported a towel is placed on the padding. | 2020-09-01 |
| 18 | 18 | HILO MEDICAL CENTER | 125002 | 1190 WAIANUENUE AVENUE | HILO | HI | 96720 | 2019-12-20 | 883 | E | 0 | 1 | P3CE11 | Based on record review, staff interview, and review of policy, the facility failed to provide education regarding benefits and potential side effects for the Influenza Vaccination that was given to two Residents ((R) 15, 28) out of the seven residents reviewed. As a result of this deficient practice, the two residents and/or their representatives was not given the opportunity, or even the discussion, of minimizing the risk for acquiring, transmitting, or experiencing complications from the Influenza vaccination. Findings Include: 1. During a review of the immunization record for R15, it was noted that R15 received the Influenza vaccination on 10/10/19. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. On 12/20/19 at 12:30 PM, the Director of Nursing (DON) was queried and subsequently provided a consent form for R15 on the Influenza immunization. However, the consent form was for the previous flu season (YEAR)-2019. There was no consent form provided for the current year 2019-2020. 2. During a review of the immunization record for R28, it was noted that R28 received the Influenza vaccination on 10/04/19. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. On 12/20/19 at 12:30 PM, DON was queried and subsequently provided a consent form for R28 on the Influenza immunization. However, the consent form was for the previous flu season (YEAR)-2019. There was no consent form provided for the current year 2019-2020. A review of the facility policy titled Influenza and Pneumococcal Vaccination Protocol for Acute Care Inpatients and Long Term Care Residents stated the following: Policy, [NAME] Hilo Medical Center Registered Professional Nurses (RPNs) and Licensed Practical Nurses (… | 2020-09-01 |
| 19 | 19 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 157 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, the facility failed to immediately notify the resident's representatives when there was a significant change in the resident's physical condition and health status for 1 of 23 residents (Resident #12) in the Stage 2 sample. Finding includes: During a confidential family interview on 04/11/2017 at 10:31 AM, a family member stated he/she is the person who would be notified of a change in condition involving Resident #12 (R #12). The family member stated there had been a recent change in R #12's health condition. The family member stated he/she had not been promptly notified by staff caring for R #12 of the laboratory tests and an electrocardiogram (EKG) that had been ordered. The family member further said the tests were ordered about a week ago on a Friday, and when he/she came to visit R #12 on Sunday, the resident was going through an exacerbation of her [MEDICAL CONDITIONS]. The family member stated the resident was also found to have swelling (edma) of her face and hands. During a follow-up confidential interview on 04/12/2017 at 9:02 AM, the family member said, I knew (the resident) was quite lethargic but not aware of the labs and EK[NAME] The family member also said there was a decline in the resident's condition and by that Sunday, 4/2/17, the on call physician was called to assess R #12. The family member stated although another family member is the primary contact (he/she) asked for me (this family member) to be contacted first due to a language barrier. The resident's clinical chart documents this family member to be the first person the facility is to call on the resident's contact list. The family member re-verified that no staff informed him/her of the labs and EKG and change in the resident's condition. On 04/13/2017 at 8:06 AM, an interview with Staff #58 was done. Staff #58 said R #12's [MEDICAL CONDITION] gets more complicated, but confirmed that when an EKG and labs are ordered… | 2020-09-01 |
| 20 | 20 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 221 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident #63 was free from a physical restraint. Finding includes: On 4/10/17 at 11:30 [NAME]M. observed Resident #63 in the activity room. The resident was seated in a wheel chair with a gait belt looped through the bars on the sides of the wheelchair and buckled across her lap. Subsequent observation at 11:42 [NAME]M. found the gait belt still buckled across the resident's lap. At 12:21 P.M. Resident #63 was observed eating lunch at a table with the gait belt still affixed to her wheelchair. On the morning of 4/11/17 Resident #63 was observed eating her breakfast in the activity/dining room, the gait belt was affixed to her wheelchair. Subsequent observation at 10:06 [NAME]M. found the resident watching the entertainment. The resident was seated on a bench in the front row. On 4/11/17 at 2:22 P.M. observed Resident #63 asking Staff Member #110 to take her back to the room. Resident #63 was seated in a wheelchair and observed to be wearing a seat belt that was buckled in the front. Resident #63 was observed to self-propel the wheelchair with her feet. The seat belt was removed by the staff member, Resident #63 was observed to stand and walk to the bathroom independently. The resident stood in front of the toilet and started pulling her pants down, at this time, the staff member requested to have the door closed. Second observation at 3:06 P.M. found Resident #63 ambulating on the unit with the assistance of a staff member. Observation from 3:14 P.M. through 3:34 P.M. found Resident #63 propelling herself in the wheelchair around the unit. The seat belt was applied. On 4/12/17 at 8:03 [NAME]M. Resident #63 was observed eating breakfast in the activity/dining room, the seat belt was not applied and there was no gait belt looped across her lap. Subsequent observation at 9:04 [NAME]M. found the resident's seat belt was affixed. A reco… | 2020-09-01 |
| 21 | 21 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 279 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure it developed and implemented a comprehensive, person-centered care plan for 1 of 23 residents (Resident #12), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment in the Stage 2 sample. Finding includes: Cross-reference to findings at F157. Resident #12 (R #12) was admitted to the facility from an acute setting as her cardiac status had stabilized. R #12's admission was for ongoing medical management and rehabilitation services (physical and occupational therapy) due to severe weakness related to her hospitalization . Some of her [DIAGNOSES REDACTED]. Observation of R #12 revealed the resident was arousable but lethargic. A family interview revealed the resident had a recent exacerbation of her [MEDICAL CONDITION] symptoms with noted [MEDICAL CONDITION] (swelling). A review of R #12's clinical chart found a 3/31/17 nursing note which documented upon assessment, the resident was noted to be diaphoretic and lethargic. Arousable but generalized lethargy .Noted increased irregular HR (heart rate) in the 120s and BP 110/79. The record revealed the attending physician was notified and ordered a stat EKG, which was done at 10:10 AM on 3/31/17. Per the attending physician's 3/31/17 note, she assessed the resident as having sinus [MEDICAL CONDITION] wheeze, questionable asthma as symptoms were recurrent, and ordered oxygen as needed. The physician also ordered a new inhalation medication ([MEDICATION NAME]) twice daily for 5 days and noted the resident's history of [MEDICAL CONDITION] and positive fluid retention, and consider checking of BNP . The lab tests drawn on 4/3/17 included a basic metabolic panel and a B-Natriuretic Peptide (BNP) level. The BNP was significantly elevated at 908 pg/mL (normal A 4/2/17 entry by the on-call physician found R #12 was ass… | 2020-09-01 |
| 22 | 22 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 280 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's basic care plan for falls was revised for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: Cross-reference to findings at F323. Resident #77 (R #77) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R #77's 3/21/17 basic care plan was formulated by an interdisciplinary team (IDT) and included care plans for self care deficit, altered thought process, alteration in comfort and a risk for falls. During an interview with Staff #13 on 4/12/2017 at 2:04 PM, she acknowledged her 3/24/17 assessment of R #77 was not included in the basic care plan with regard to the resident's with left sided weakness, difficulty in communicating, confusion, and functional limitations in her mobility and transfer. Staff #13 said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. She said her entry on 3/24/17 was about therapy and the IDT care plan (on 4/4/17) included additional interventions, but that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview with Staff #55 revealed the family stated the resident fell all the time at home. Staff #55 confirmed the resident sustained [REDACTED]. Staff #55 said she would have to look to see if she discussed it with the nurse manager at the time, but the nurse manager should have incorporated it into the resident's care plan. This was in relation to Staff #13's progress note entry of 3/24/17 that based on her assessment of the resident, the recommended plan was to support R #77's left upper extremity at all times, to respond as quickly as possible to her requests to toilet, provide two staff assistance for putting on briefs, and provide program and training for staff to maximize the resident's ADL safety, independence, mobility and quality of life. This was not found in the basic ris… | 2020-09-01 |
| 23 | 23 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 281 | D | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure the services being provided meet professional standards of quality according to accepted standards of clinical practice for 2 of 23 residents (Residents #43 and #76) in the Stage 2 sample. Finding includes: 1) During Resident #43 (R #43's) room observation on 4/10/17 at 2:42 PM, it was noted that she received enteral nutrition via [DEVICE] feedings (GTF). The enteral nutrition (EN) bag that was hanging on the IV pole but not being infused at the time was Fibersource HN. On the bag's label, it had the resident's handwritten name as initials. It was also dated 4/10/17 and 370 cc/hr written on it. There was no start time written on the label when the initial EN infusion began. R #43's physician's orders [REDACTED]. Review of the facility's policy on Enteral Tubes was provided on 4/12/17, but it did not address how the EN formula bags were to be labeled. On 04/13/2017 at 7:25 AM, a room observation was done with Staff #108 for R #43. The resident's EN bag that was hanging on the IV pole had the resident's handwritten name as initials, and 4/12 1300 on it. Staff #108 said, It's missing the feeding order. Staff #108 further said their policy says the EN bag should be labeled with the amount of the flow rate on it. Staff #108 stated, it's not acceptable, and also verified the way staff had labeled the EN bag per surveyor's 4/10/17 observation by omitting the start time was not acceptable. The State Agency references the American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN), The Journal of [MEDICATION NAME] and Enteral Nutritional Practice Recommendations, Bankhead, R., et al., [DATE], pp. 129-130: D. Labeling of Enteral Nutrition .Practice Recommendations .3. All EN labels in any healthcare environment shall express clearly and accurately what the patient is receiving at any time .4. The EN label should be compared with the EN order f… | 2020-09-01 |
| 24 | 24 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 323 | G | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: A Stage 2 review was done based on an incident report (IR) involving a fall related injury sustained by Resident #77 (R #77). The facility's self-reported IR stated the resident's 3/25/17 fall appeared to have .more affected her shoulder which was already affected by the cva. She is forgetful at times and does not remember to use the call bell. She does not realize that the left side of her body does not support her anymore. What interventions were implemented after the incident/event to prevent further injury? Immediate measures: 1:1 supervision while in bed and visual supervision when out of bed. Toileting at least every 2 hours with the goal of working on promoting continence, PT/OT have done initial evaluations with resident on 3/23-24 and will be working with resident to increase physical capabilities which will help with all aspects of care and comfort. On site review found R #77 was admitted to the facility on [DATE] from the hospital with several [DIAGNOSES REDACTED]. The resident's chart review found her admission included rehabilitation services (physical and occupational therapy) and that she has confusion. The resident's unwitnessed fall occurred on 3/25/17 in her room, and at the time of the incident, she stated she wanted to go to the bathroom. As a result of the fall, R #77 sustained a left shoulder subluxation (dislocation) injury. The emergency department noted it was a difficult reduction of the shoulder injury and she was given a left arm sling to stay on for at least 7 days. Observation of the resident on 4/12/17 at 10:16 AM in the hallway found she still required the use of a sling. The resident was… | 2020-09-01 |
| 25 | 25 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 334 | F | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and review of the facility's policy and procedure, the facility failed to ensure 5 (Residents #70, #63, #34, #56 and #57) of 5 residents sampled for immunization had the opportunity to refuse the influenza vaccine. The resident's medical record does not include documentation that the resident or resident's representative was provided with education regarding the benefits and potential side effects of the influenza immunization and the resident received the immunization or refused the vaccination. Findings include: On 4/10/17 the facility provided a copy of the the policy and procedures for Vaccination Pneumococcal and Influenza Inpatient Protocol. The procedure includes if a resident is indicated for the vaccine, the facility will provide the :Vaccine Information Statement (VIS) and will review the appropriate VIS with the resident prior to the administration of the vaccine. The required documentation includes: patient/family education; the date of administration of the pneumococcal vaccine; amount and dosage given; the site of injection; the vaccine manufacturer; the lot number of the vaccine used; the expiration date of the vaccine; and signature of licensed nurse administering the vaccine. The policy did not include provision for the resident or resident's representative to refuse immunization. On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members reported the process for immunizations include sending a letter to the resident or resident's representative to offer the vaccine with the VIS attached. The letters are sent out in (MONTH) and November. Staff Member #122 provided a sample of the immunization packet that is sent to the resident or resident's representative. The letter was reviewed during the interview which notifies the resident or resident's representative that All residents at (facility name) are sche… | 2020-09-01 |
| 26 | 26 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 353 | F | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and facility policy reviews, the facility failed to provide sufficient nursing staff based on the staff's inability to provide the necessary care and services based on the resident assessments to ensure each resident is able to reach their highest practicable physical, mental and psychosocial well-being. Findings include: During the interview with the NHA and DON on 04/13/2017 at 10:22 AM, the NHA agreed they have had a staffing problem such that per the DON, the need for coverage was so great, due to the transition and sick calls. The DON also said they were often short 38% of their staff. The NHA said by not having a quality nurse position filled for about 1.5 years, they have seen doubling up of responsibilities with their remaining staff, which has led to a lack of identification of opportunities (for improvement) and they have become more reactive than proactive. The NHA also said it included the communication piece as well. The DON further stated with a 13 week turnover interval for the [MEDICATION NAME] (out of state travel nurses and nurses aides), there was less consistency in the delivery of care to their residents. She stated the real issues thus were not being addressed. The cumulative findings in the areas of Resident Rights, Resident Behavior and Facility Practice, Quality of Care, Quality of Life and Pharmacy Services demonstrates widespread concerns, including harm and substandard quality of care, which are interdisciplinary and includes nursing and administrative services. This deficiency is directly related to the lack of an effective quality assurance and assessment program, to which it is cross-referenced at F520. It is also evidenced and cross-referenced to the survey findings at F157, F221, F279, F280, F281, F323, F334, F371, F425, F431, F441 and F490. | 2020-09-01 |
| 27 | 27 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 371 | E | 0 | 1 | 1M3411 | Based on observations, staff interviews and facility policy review, the facility failed to maintain a walk in refrigerator and walk in freezer to ensure proper food storage. Findings include: An initial tour of the kitchen on the morning of 4/10/17 at approximately 9:30 [NAME]M. found a walk-in refrigerator and the walk in freezer both of which didn't latch when the door was left to shut on it's own. When shutting the door, the door did not completely shut until a staff member pressed it against the door frame. The top edge of the refrigerator door appeared uneven, sloping downward from left to right. At the top of the door, the space between the left side of the walk in refrigerator door and the refrigerator door frame had a gap of approximately 2 inches and narrowed toward the bottom to approximately 0.75 inches. The temperatures for the walk in refrigerator were maintained at or below 41 degrees. However, the possibility for the temperature to rise above 41 degrees was high based on the necessity for the the staff to push the door shut. In addition to the walk in refrigerator, the walk in freezer also did not latch when the the door was left to shut on it's own. A sign was taped to the freezer door to remind staff to push the door shut. When shutting the freezer door, the door did not completely shut until a staff member pressed it against the door frame. The edge of the freezer door appeared uneven, sloping downward from left to right. At the top of the door, the space between the left side of the walk in freezer door and the freezer door frame had a gap of approximately 2 inches and narrowed toward the bottom to approximately 1 inch. A gray strip around the freezer door was loose at the corner. The Maintenance staff re-glued the gray strip until it was permanently fixed. Additionally, the floor was wet under the door to the walk in freezer. Staff #12 reported that she thought the wetness was from condensation. The temperatures for the walk in freezer were maintained at or below 0 degrees. However, the possib… | 2020-09-01 |
| 28 | 28 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 425 | F | 0 | 1 | 1M3411 | Based on observations, interviews, and policy reviews the facility failed to utilize the pharmacy for consultation services on all aspects of the provision of pharmacy services in the facility. Findings includes: Cross to F 431 1) On 4/12/2017 at 10:40 AM interviewed Staff #116 regarding the procedure for discarding discontinued narcotics. Staff #116 stated that liquid narcotics are disposed into the drain and the controlled pills are discarded into the sharps container. The policy for disposal of discontinued narcotics was provided by Staff #116 and reviewed. The policy dated 12/12 stated: 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. 2. Controlled Substances listed in Schedules II, III, IV and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center - until destroyed as outlined by state regulation. a. Transfer to a container for release to a pharmaceutical waste contractor, was checked off on the policy. At 1:36 PM the same day interviewed the DON regarding nursing practice for disposal of discontinued resident narcotics. The DON shared the policy for disposal of controlled drugs used on the nursing floors dated 12/12 is old, a new policy dated 5/16 is on line but has not been changed in the PharMerica policy binders used by the nursing staff. At 1:41 PM the same day interviewed Staff #108 regarding disposal of narcotics procedure. Staff #108 stated the narcotics are popped out of the bli… | 2020-09-01 |
| 29 | 29 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 431 | F | 0 | 1 | 1M3411 | Based on observation, interviews, and policy review the facility failed to provide pharmaceutical services to meet the needs of each resident. Findings include: Cross reference to F 425 1) On 4/10/2017 at 11:50 AM observed an IV bag hanging for Resident #44. The IV bag was not labeled with a resident's name or dated. At 12:00 PM interviewed Staff #116 regarding the unlabeled IV bag. Staff #116 agreed the bag hanging should be labeled. Staff #116 shared Resident #44 receives TPN nourishment through her PICC line and after the TPN is infused an IV bag is hung until the line is flushed. Staff #116 brought out an unopened IV bag to show that the pharmacy label is attached to the outside plastic wrap of the IV bag, when the bags are opened the pharmacy label is discarded. Unlabeled medications has the potential for medication errors. 2) On 4/12/2017 at 8:13 AM observed an unlocked treatment cart with one drawer pulled out resting in the hall outside of the dining hall. The opened drawer contained ointments. There was no staff seen near or around the opened cart. Shortly after observed Staff # 116 came out of the dining room. Staff #116 was asked about the unattended, unlocked treatment cart with the treatment drawer opened. Staff #116 stated she went to check a resident and had left the cart unlocked. Staff #116 agreed the cart should have been locked. Unlocked treatment carts has the potential for medication loss and misuse. 3) On 4/12/2017 at 10:40 AM interviewed Staff #116 regarding the procedure for discarding discontinued narcotics. Staff #116 stated that liquid narcotics are disposed into the drain and the controlled pills are discarded into the sharps container. The policy for disposal of discontinued narcotics was provided by Staff #116 and reviewed. The policy dated 12/12 stated: 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. The nursing care center should maintain approved containers to se… | 2020-09-01 |
| 30 | 30 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 441 | F | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with staff member, the facility failed to establish and maintain an effective infection prevention and control program including the tracking and analyzing of outbreaks of infection. Findings include: 1) On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members were asked how they collect, trend and analyze their data related to infection control. Staff Member #122 reported the nurses will submit infection surveillance forms to report any concerns regarding infections as well as discuss infection issues in daily rounds. This information is collected for data and reviewed for trends. The staff member also reported the infection program also tracks the immunization process. The DON and Staff Member #122 confirmed the facility had an outbreak of Norovirus in (MONTH) (YEAR). The Norovirus reportedly was isolated to the 4th floor; however, a resident on the 3rd floor also had Norovirus. Further queried whether the facility determined the source of the Norovirus outbreak. Staff Member #122 responded it's impossible to figure it out; however, the facility makes note if a cruise ship was in the port and possibly the Norovirus may have come from the children visiting from the school or a staff member being infected from their child. The data and trends collected by the facility were not specific enough to identify the origin of the Norovirus. A request was made to review their infection log/data. The facility provided data from (MONTH) (YEAR) through (MONTH) 6, (YEAR). The data included the resident's name, medical record number, room number, type of infection, culture, antibiotic and comment. The staff members were queried whether the infection control program determines whether infections were hospital or community acquired. The response was they did not think this is part of the policy to track whether infections are hospital or community acquired. Further d… | 2020-09-01 |
| 31 | 31 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 490 | F | 0 | 1 | 1M3411 | Based on record review, interviews and review of the facility's policies and procedures, the facility failed to ensure it is administered in a manner that enables it to use its resources effectively and efficiently in order for the residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding includes: There is non-compliance with this regulation based on the deficient findings/outcomes in the areas of Resident Assessment, Quality of Care with substandard quality of care and harm for R #77, Quality of Life, Nursing Services and Pharmacy services. This is evidenced and cross-referenced at F157, F221, F279, F280, F281, F323, F334, F353, F371, F425, F431, F441 and F520. Inclusive are the survey observations, interviews, record reviews, and reviews of the facility's policies and procedures. Per interview with the NHA on the morning of 4/21/17, he acknowledged the preliminary survey findings and stated that aside from the transition period the long term care unit is going through, he attributes the lack of an effective QAPI (quality assurance and performance improvement) program to have been a factor that may have prevented the facility to have identified these care related issues found by the State Agency. The NHA also stated they have taken steps to remedy how quality improvement measures and policy making will be addressed by their governing body in the future. | 2020-09-01 |
| 32 | 32 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 520 | F | 0 | 1 | 1M3411 | Based on observations, record review, interviews and review of facility policies, the facility failed to maintain an effective quality assessment and assurance (QA&A) committee which included analyses of identified performance improvement activities, including specific standards for quality of care and related outcomes for their residents. Finding includes: On 04/13/2017 at 10:22 AM, an interview with the NHA, DON and Staff #122 was done. They were asked about their quality assurance/performance improvement (QAPI) plan and what quality care areas were being reviewed. The DON stated each department attends their QAPI meetings to discuss department specific PI projects. The DON said they also review the Casper Report and what their triggers were. The NHA stated they also reviewed their audits on documentation, such as the prior survey's bathing citation as an example. The NHA said the nurse managers were actively involved in the audits as well. The DON and NHA concurred however, that most of their PI work has been focused on the transition process with their facility to transfer management to a new entity effective 7/1/17. Despite knowing the needs of the long term care unit and the need to maintain the quality of care, they both acknowledged their focus has been directed on the lack of staffing related to the transition. The NHA said their QAPI meetings entailed more of a review of the Casper Report in aggregate and were general discussions about their dashboard. They acknowledged the State Agency's preliminary quality concerns found during the survey, but yet were unable to demonstrate they had identified similar concerns, or any new concerns using their own PI methodology to demonstrate an effective PI program. Thus, based on the State Agency's clinical outcomes and quality concerns, the facility failed to demonstrate areas of quality performance improvement measures, including the identification of, or monitoring the effect of any implemented changes and with improvements to their action plans. The facility's p… | 2020-09-01 |
| 33 | 33 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2019-05-31 | 657 | D | 0 | 1 | IFL211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review (RR) and observation, the facility failed to revise/update changes in the care plan for three of 18 residents (R16, R6, and R279) in a timely manner. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions and monitoring to promote effective continuity of care to safeguard against adverse events may not have occurred. This has the potential to affect all other residents in the facility. Findings include: 1)Interview on 05/29/19 at 09:09 AM with resident (R)6 who states sometimes my bowel movement is like a golf ball and sometimes I drop one or two and sometimes I go six or seven times a day and it is like golf balls . They are not giving me anything for the bowel movement. Record Review (RR) on 05/30/19 at 09:19 AM reveals doctors orders for 1) [MEDICATION NAME] evacuation 10 mg suppository. 2) Milk of Magnesia (Mom) in evening if not adequate bowel movement for to days. 3) Enema use one rectally whenever necessary if no/inadequate bowel movement for two days. RR and concurrent interview with Nurse manager, staff(S)2 on 05/31/19 at 10:02 AM shows no care plan was developed for constipation. This was confirmed with S2. 2) RR of R16 revealed she was taking an anticoagulant/blood thinner (Xarelta) for a [DIAGNOSES REDACTED]. She was transferred to an acute care hospital on [DATE] for possible [MEDICAL CONDITION]. The blood thinner was discontinued at that time. R16 was readmitted to the facility on [DATE]. She was restarted on the blood thinner after her condition stabilized on 02/28/19. Review of R16's care plan failed to reveal any goal, interventions, or monitoring for complications related to the blood thinner. On 05/30/19 at 09:23 AM, during an interview with Unit Manager (UM1), queried if R16's care plan included monitoring for complications of a blood thinner. UM1 said, the care plan wasn't updated. UM1 agreed monitoring R16 for complications related to… | 2020-09-01 |
| 34 | 34 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2019-05-31 | 686 | G | 0 | 1 | IFL211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to intervene in a timely manner when the resident refused to remove compression gloves to left hand for five days. As a result of this deficient practice, R54 out of two sampled residents (R54 and R23) developed a Stage 4 pressure ulcer to the left fifth digit. Findings include: Observation on 05/30/19 at 12:03 PM of R54's dressing change with Staff(S)1. S1 stated, R54 acquired the wound in the hospital and his finger was amputated. R 54 wears compression gloves for [MEDICAL CONDITION] arthritis associated with joint pain in his hands. R54 had compression gloves on and would refuse to take them off or let the nurses monitor his hand and it was too late. Record Review on 05/30/19 at 01:01 PM shows in the past, R54 requested that his 4th finger on left hand be removed due to contracture, pain and a buttonneire deformity. Treatment record of doctors orders written on 01/14/18 to monitor both hands for impaired skin integrity twice a day. (Gloves off 04/13/19). Treatment record comments shows on 4/08/19 the resident declining to remove gloves up until 04/13/19. On 04/13/19, documentation stating wound skin impaired noted to left 5th digit. Doctor notified. From that point on, gloves were off. Progress notes dated 04/13/19 states R54 was complaining of pain to touch to left 5th digit of left hand. Resident did not want to remove gloves at first. Resident removed it later and left 5th digit by flexor/crease with wound open 1.3 centimeter length. Whitish, pink with scant bleeding. Cleansed with normal saline and covered. Called doctor at 10 AM and informed of open wound to left 5th digit. Keep clean and open to air. Further RR reveals doctor visit on 04/13/19 at 1400. Doctors exam confirmed R54's left fifth finger with open wound at proximal interphalngeal (PIP) joint, tendon visible, wound moist, swelling and [DIAGNOSES REDACTED]. Appears to have infection and swelling and [DIA… | 2020-09-01 |
| 35 | 35 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2019-05-31 | 842 | D | 0 | 1 | IFL211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have accurate information in the medical record of one of 18 sampled residents. The medical record for R61 had conflicting information on the Advanced Healthcare Directive (AD) and the Provider Orders for Life-Sustaining Treatment (POLST). An AD is a legal document used to provide guidance about what types of treatments you may want in case of a future unknown emergency. A POLST form is a medical order for the specific treatments you want during a medical emergency. A POLST form does not replace an advance directive, but they work together. Findings Include: A review of R61's Advanced Care Planning documents revealed the POLST and AD had conflicting information. The POLST (Section C, artificially administered nutrition) signed by Surrogate dated 01/31/13 includes an order for [REDACTED]. During an interview with Social Worker (SW1) on 05/29/19 at 01:44 PM, inquired what the process was to obtain advance directives on admission. She stated, most of our residents come from acute care and they do them there and send with the resident. If they do come from the community, the SW will ask on admission if they have one, and give them information in the admission packet. When asked who was responsible for viewing the content of the advanced care planning documents to ensure they matched, and she said, I'm not sure. | 2020-09-01 |
| 36 | 36 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2018-06-22 | 584 | D | 0 | 1 | GCA011 | Based on observation and interview, the facility failed to ensure the bedroom landing mats placed at the bedside was sanitary, safe and in good condition for 1 of 24 residents (R33). In addition, the facility failed to ensure the bathroom floor's black skid strips were in good condition for 1 of 24 residents (R56) and a dining room table was maintained in good, safe condition. Findings Include: 1) During the observation of Resident 33's (R33) bedside landing mat on 06/20/18 at 08:43 AM, it was found that both of the resident's beige colored landing mats had long cracks and tears throughout. As a result, some of the woven mesh underneath the beige cover could be seen. 2) During a bathroom observation 06/20/18 at 08:31 AM, it was found that R75's bathroom floor had large black skid strips that were peeled off and missing on four of the strips. 3) On 06/21/18 at 09:34 AM, during a concurrent room observation with Staff 5 (S5), she confirmed the beige floor mats for R33 were in disrepair, worn and torn. S5 said the mats needed to be replaced. S5 also concurred it did not present to be a safe and clean home environment, as there was a potential risk for falls due to the tears on the surface of the mats, and that the mats were potentially unsanitary due to the exposure of the woven material visible through the tears. 4) On 06/20/18 at 09:07 AM, R56 was observed holding onto the edge of a round table in the activity/dining room on 4 North. Portions of the table's white laminate type of siding were missing/torn off, leaving an uneven surface that could potentially affect (poke or scratch) one's skin. R56 gripped onto the side where the missing laminate was and used her hands to push and pull her wheelchair back and forth. No staff was present to observe her. On 06/21/18 at 09:52 AM, a concurrent observation of the activity/dining room on 4 North was done with S5. S5 verified there were portions of white siding missing on the table's edge. S5 said she did not want anything to cause injury to the residents and maintenance … | 2020-09-01 |
| 37 | 37 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2018-06-22 | 689 | D | 1 | 1 | GCA011 | > Based on observation, record review and interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible, and each resident receives adequate supervision to prevent accidents for 2 of 38 residents (R56 and R31) reviewed. Findings Include: 1) On 06/19/18 at 11:18 AM, R56 was observed sitting at a table with oversized red Lego-type and wooden building blocks on it. The building blocks were being used by another resident, R71, who is blind. R56 had already grabbed one of the large red blocks and was trying to insert it into her mouth but it was too big. After licking it, she put it down on the table. She then grabbed a blue rectangular wooden block and tried to insert that large block into her mouth as well. S15 was in the hallway and was asked to observe R56. S15 intervened and said R56 was not supposed to be handling these building blocks. The blocks were pushed toward R71 without being sanitized and R71 resumed using them. S15 said it was not okay that R56 was found putting the big wooden block into her mouth or the other red blocks. S15 said they were only staffed with one aide and although their activity room got very crowded, it was how they're running us more now. S94 then moved R56 to her usual table in the adjoining room. S94 said the aide who had been sitting next to R56 left, and she was tending to residents on the other side. Observation found there are walls which separated the three adjoining rooms. As a result, staff attending to residents in the first TV room where most of the residents congregated, could not fully view the residents in the middle room by the round table against the wall. And, if staff were in the first room, they would not be able to see the residents in the third low stimulation room, unless the resident sat on the couch in the low stim room. Otherwise, their view was blocked by the side walls. Thus, when R56 was found with the building blocks in her mouth, although S94 was in the first room, she could not see R56 and had been… | 2020-09-01 |
| 38 | 38 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2018-06-22 | 725 | D | 0 | 1 | GCA011 | Based on observation, record review and interview, the facility failed to ensure it has sufficient nursing staff to provide nursing and related services to assure resident safety and for each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being for 11 of 24 residents (R56, R71, R31, R46, R75, R6, R39, R16, R30, R40 and R44) on one of the 4th floor nursing units. Findings Include: Cross-reference to findings at F689. On 06/19/18 at 10:55 AM, R56 was found in the hallway yelling out loud that she wanted to go to the activity room. Even after two minutes of yelling, no staff attended to her. At 10:57 AM, surveyor approached S15 who was standing by a medication cart at the end of the hallway. S15 stated S90 had just brought R56 into the hallway after toileting her. However, the resident remained yelling while trying to push her wheelchair forward, but could not move. S90 then attended to the resident and wheeled her into the activity room. The nursing unit's census included 24 residents. On 06/19/18 at 11:28 AM, there were ten residents in the activity room. There was one certified nurse aide (S94) who was attending to R75 at the time. One resident, R6, was loudly mumbling words over and over and tried to reach out and grab other people while sitting at her table. R71 was observed touching the wall, touching the building blocks in front of her and/or sat trying to move her wheelchair around. S94 was not able to either calm or attend to these residents one to one, as they were spread out in two of the adjoining rooms. Then after the incident with R56 whereby she was found trying to insert the large building blocks into her mouth, S94 stated, We only have one staff in here usually and it's really hard with just one staff. On 06/19/18 at 12:30 PM, during the lunch observation, it was found that R31 was able to feed herself. By 12:39 PM however, the spinach and beans were pushed toward the edge of her plate and ready to come off. The same observation was made earlier for R46… | 2020-09-01 |
| 39 | 39 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2018-06-22 | 812 | D | 0 | 1 | GCA011 | Based on observation, interview and policy review, the facility failed to distribute food to residents in a sanitary manner. The deficient practice placed residents at risk for illness, infection and the potential for foodborne illness. Findings Include: During the lunch observation on 06/19/18 at 12:41 PM, Staff 36 (S36) was passing trays to the residents. S36 was observed to wipe his brow and touch his cheek on two occasions, and did not sanitize his hands before passing a tray to the next resident. S36 was observed to empty a tray into the refuse can and then passed another tray to a resident without sanitizing his hands. During an interview with S36 on 06/19/18 at 02:45 PM, he stated he didn't sanitize his hands after throwing food into the garbage or when he proceeded to get another resident's tray. S36 said, I guess I had the white coat syndrome. Review of the Hand Hygiene policy 125-500-020 stated, To reduce to as low as possible, the number of viable microorganisms on the hands in order to prevent transmission of healthcare associated pathogens from one patient to another, and to reduce the incidence of healthcare associated infections. 4. Before eating, after eating, . S36 did not follow sanitary hand hygiene practices. | 2020-09-01 |
| 40 | 40 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2018-06-22 | 849 | D | 0 | 1 | GCA011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility and the hospice did not collaborate in the development of a coordinated plan of care for 1 of 3 residents (R179) receiving hospice services. Findings Include: On 06/20/18 at 08:17 AM, R179 was heard yelling from her room. Staff 6 (S6) stated R179 was a hospice resident. S6 said when staff attends to her yelling, she tells them that she didn't know she was yelling. Surveyor went to R179's bedside and asked her if she was in pain. R179 replied, Yes, all over. A staff came into R179's room to get towels from the closet and stated she would attend to R179 after finishing up with another resident. S6 came to assess R179's pain and informed S22. After adjusting R179's position and pillows, S22 asked resident what type of pain meds she preferred, either [MEDICATION NAME] or Tylenol. R179 stated, Do I have a choice? When queried later, S22 stated that R179 used to be able to say what type of pain she had (e.g., pain level of 9-10), but from yesterday, she was unable to. S22 said, [MEDICATION NAME] is prn every 4 hrs and last dosage given last night at 20:15 (8:15 PM). S22 stated she just gave R179 [MEDICATION NAME] because, Resident was crying so probably severe pain. After receiving the pain meds, R179 was provided breakfast and observed that resident ate without pain and a CNA assisted her. On 06/20/18 at 08:38 AM, interviewed S6. He stated that R179 will be discharged from hospice because the resident was admitted as hospice but as full code and that it did not make sense to him. S6 talked to the hospice provider and was told the hospice provider got into trouble for not accepting residents who were full code and R179 was placed into hospice care at the hospital she was transferred from. The [DIAGNOSES REDACTED]. The hospice benefit period was 06/08/2018 - 09/05/2018. The hospice physician's signature on 06/08/18 also included information of the resident's code status (attempt resuscitation); … | 2020-09-01 |
| 41 | 41 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2018-06-22 | 880 | D | 0 | 1 | GCA011 | Based on observation and interview, the facility failed to ensure it maintained a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 24 residents (R56, R71) in the sample. Findings Include: On 06/19/18 at 11:18 AM, R56 was observed sitting at a table with oversized red Lego-type and wooden building blocks on it. The building blocks were being used by another resident, R71, who is blind. R56 had already grabbed one of the large red blocks and was trying to insert it into her mouth but it was too big. After licking it, she put it down on the table. She then grabbed a blue rectangular wooden block and tried to insert that large block into her mouth as well. S15 was in the hallway and was asked to observe R56. S15 intervened and said R56 was not supposed to be handling these building blocks. The blocks were pushed toward R71 without being sanitized and R71 resumed using them. On 06/21/18 at 09:38 AM, S5 said they have one person to monitor the three adjoining activity rooms. S5 was informed of the observation whereby the blocks were not sanitized before it was given to R71, but had no comment. S94 said a lot had been going on that day when R56 tried to insert the blocks into her mouth. S94 said they usually wiped each block with the purple top disinfecting wipes and dried them for a couple minutes before putting them away. However, on 06/19/18 the blocks were not sanitized before they were returned to R71. | 2020-09-01 |
| 42 | 42 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2019-07-12 | 550 | D | 0 | 1 | QXJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff members, the facility failed to ensure a resident is provided care with respect and dignity to promote and enhance her quality of life during skin assessments resulting in the resident feeling embarrassed. Findings include: Resident (R)78 was admitted to the facility on [DATE] from an acute facility. R78 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. On 07/09/19 at 10:50 AM an interview was conducted with R78. R78 reported that she is uncomfortable with the skin assessment, it made her feel like a criminal. The resident clarified, she asked to undress and lay in bed for the skin assessment. R78 further reported another staff member was also present. Queried whether the staff member draped her body during the assessment, R78 replied, no. R78 also shared that she doesn't understand why another staff member has to be present and was not asked whether it was okay to have another staff member present during the assessment. R78 also stated that she doesn't understand why the skin assessment has to be done weekly. On 07/12/19 at 08:15 AM an interview was conducted with Licensed Nurse (LN)2. Inquired how are skin assessments performed. LN2 reported residents usually come from the acute hospital and are dressed in a hospital gown. LN2 reported residents are not asked to undress and are informed the nurse will check their bottom and for women, look under their breast. LN2 further explained the resident's hospital gown is removed only to expose areas that are being assessed. The LN confirmed there are two nurses present during the skin check to assist with turning and one person to write and one person to measure. A record review was done on 07/10/19 at 01:19 PM. A review of the admission Minimum Data Set (MDS) with assessment reference date of 06/21/19 found R78 yielded a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. R78 … | 2020-09-01 |
| 43 | 43 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2019-07-12 | 689 | D | 0 | 1 | QXJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to utilize a bedside blue mat, as indicated on the care plan for Resident (R) 2. With this deficient practice, the facility put R2 at risk for increased accident hazards. Findings Include: Resident 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the latest minimum data set ((MDS) dated [DATE] revealed that R2 had a brief interview of mental status (BIMS) score of 3 indicating the resident had severe cognitive impairment. The resident was assessed to require extensive assistance, dependent with all activities of daily living (ADL's). A review of the MDS Coordinator's note showed that R2 was at risk for falls, due to depression and taking [MEDICAL CONDITION] medication. On 07/09/19 at 01:36 PM, R2 was observed in his room, sleeping on his bed. At the same time, a blue bedside mat observed not in use and leaning up against two chairs. On 07/10/19 at 07:20 AM, R2 was observed in his room, sleeping on his bed. At the same time, the blue bedside mat was again not in use and leaning up against two chairs. On 07/10/19 at 10:30 AM, R2 was observed in his room, lying in his bed. This time; however, the blue bedside mat was now in use, placed on the floor next to R2's bed. On 07/10/19 at 01:25 PM, Licensed Nurse (LN) 3, was interviewed about the bedside mat usage. LN3 stated that whenever R2 is lying or sleeping in bed, the blue bedside mat should be used and placed on the floor next to the bed and the care plan should say that as well. On 07/10/19 at 01:25 PM A review of R2's care plan stated the following: Problem: resident is at risk for falls due to confusion and resident is very forgetful, requires assist with ADL's. Interventions: bedside blue mat initiated on 04/23/18. | 2020-09-01 |
| 44 | 44 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2019-07-12 | 842 | E | 0 | 1 | QXJ511 | Based on record review, staff interview, and review of a list of approved abbreviations provided by the facility, the facility failed to use approved abbreviations and/or acronyms when charting in the progress notes, for four of the nine residents reviewed. With this deficient practice, there was a risk of misinterpreting the un-approved abbreviations and thus causing adverse outcomes for any, or all the residents. Findings Include: 1. During review of the clinical notes for Resident (R) 11, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OOP, SO. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 2. During review of the clinical notes for Resident (R) 27, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OOP, ATB. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 3. During review of the clinical notes for Resident (R) 61, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OTA, ABT, CDI. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 4. During review of the clinical notes for Resident (R) 12, the following abbreviations/ acronyms were used, in various places, in the clinical notes: P[NAME], ASE, ABT. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. On 07/11/19 at 02:24 PM, an inquiry regarding facility approved abbreviations with the Chief Nursing Officer (CNO) was made. CNO provided the list of facility approved abbreviations titled Garden Isle Healthcare, Accepted Abbreviations - Medical Terminology which is currently in use an… | 2020-09-01 |
| 45 | 45 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2019-07-12 | 880 | D | 0 | 1 | QXJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy and protocol (P&P) review, the facility failed to ensure that staff used infection prevention and control program (IPCP) standard precautions in wound dressing change for 1 of 2 residents observed for dressing change. The deficient practice put resident (R)25 at risk for an infection. Findings Include: On 07/11/19 at 10:00 AM observed licensed nurse (LN) 1 prepare for dressing change to R25's [DEVICE]. LN1 gathered the dressing change supplies from the treatment cart and dropped the normal saline (NS) ampoule onto the floor, which was picked up and placed into the plastic basket with the other clean dressing supplies. In R25's room observed LN1, who placed the plastic basket of supplies onto R25's overbed table with paper towels underneath, and then helped to reposition R25 with clean gloves on. LN1 changed gloves without sanitizing hands, and then removed the soiled dressing from the PEG site. LN1 was also observed to use the NS ampoule that was dropped on the floor in the dressing change. After leaving R25's room informed LN1 of observations as written above. LN1 stated that she should have discarded the dropped NS [MEDICATION NAME], and changed her gloves after removing the soiled dressing but forgot. On 07/12/19 at 08:07 AM interviewed the DON on the facility's IPCP and she stated that staff are inserviced right there and then, when seen with improper hand hygiene and/or glove changes. The last hand hygiene inservice was held on 04/23/19. The facility's policy and protocol for dry, clean dressing was revied and it was noted that it was last updated on 09/14/17, and states, Steps in the Procedure; . 4. Have biohazard or plastic bag readily available . 6. Wash and dry your hands thoroughly; 7. Put on clean gloves and remove and discard dressing; 8. Wash and dry your hands thoroughly; 9. Open dry, clean dressing(s). 12. Wash and dry your hand thoroughly; 13. Put on clean gloves. | 2020-09-01 |
| 46 | 46 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2018-07-13 | 578 | E | 0 | 1 | 2CGJ11 | Based on electronic medical record (EMR) reviews, interviews and policy review, the facility failed to ensure that for a resident who does not have an advance directive (AD), the resident (R) was informed of his or her right to develop one, provided assistance in doing so or was periodically reassessed in his/her decision making capacity to do such, for 5 of 33 residents (R6, R79, R54, R60 and R73) in the survey sample. Findings Include: 1) An EMR review conducted for R79 on 07/11/18 at 8:21 AM revealed this resident did not have an AD, but only a POLST. On 07/12/18 at 3:47 PM, during an interview with the Social Services staff, they confirmed R79 did not have an AD, but only a POLST. 2) An EMR review conducted for R6 on 07/11/18 at 9:46 AM revealed he did not have an advance directive (AD), nor were there clinical notes showing the resident was informed of his right to develop one or provided assistance in doing so. 3) On 07/11/18 01:03 PM the EMR review for R54 found that the resident had a Designation of Code status acute care form signed by his spouse on 8/20/12; the form designated do not resuscitate, (DNR). On 07/12/18 at 02:00 PM interviewed the resident care manager (RCM) on the Kona unit and she validated that R54 did not have an advanced directive on file. The RCM stated that 54's spouse was coming to the facility and the SW would be discussing AD with her. 4) The EMR review for R73 noted on the physicians orders (PO), DNR. On 07/12/18 at 01:58 PM interviewed the Kona unit RCM who provided a designation of code form that was signed in 12/2012. The RCM stated that the form was a POLST, and not an advanced directive form. 5) The EMR review for R60 found that a POLST was signed on 11/03/15. On 07/12/18 at 2:02 PM validated with the Kona unit resident case manager (RCM) that R60 did not have an advanced directive on file. A review of the facility's policy and procedure (P&P), Advanced Directive (effective date 9/1/2017) stated, . 5. Social Services will check with resident/guest or resident/guest representa… | 2020-09-01 |
| 47 | 47 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2018-07-13 | 584 | D | 0 | 1 | 2CGJ11 | Based on resident and staff interview the facility failed to ensure that the personal property for 1 of 33 residents (R60) on the survey sample was not lost or stolen. Findings include: On 07/10/18 at 12:32 PM during interview of R60, she reported that she had a pink and white sleeveless dress that was sent for wash to the facility laundry and never returned. The resident stated that the dress has been missing for couple weeks now. On 07/12/18 at 02:06 PM interviewed LN19 about the facility procedure when a resident reports about a missing personal item. LN19 stated that if laundry was not returned, then staff would ask the laundry department and help the resident to locate the item. If staff were unable to find the missing item, a facility form was used to report to the social worker that the resident is missing personal item(s). The social services department would help the resident resolve the missing item. The resident reported to LN1 about the missing dress, and LN1 stated that a missing item form was not completed because the dress was returned the day after the resident reported it missing. According to LN1, R60 also told her that it was found. Both LN19 and LN1 stated that they would clarify with R60 about the missing dress. On 07/13/18 at 11:30 AM queried R60 if her missing dress was found and she reiterated that the pink and white dress did not return from the laundry and told staff again that it wasn't in her closet. Interviewed LN19, and she validated that staff went through clothes with R60 and the pink and white sleeveless dress was not found. The staff completed a missing item form which was sent to social services for follow-up. | 2020-09-01 |
| 48 | 48 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2018-07-13 | 641 | D | 0 | 1 | 2CGJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) review and staff interview the facility failed to accurately assess and code in the minimum data set (MDS) for 1 of 33 residents (R4) on the survey sample. Findings Include: On 07/10/18 at 01:44 PM during EMR review for R4 it was noted that the resident required one person support for bed mobility on the MDS dated [DATE], and the MDS dated [DATE] noted R4 required two plus persons physical assist for bed mobility. On 07/12/18 at 11:05 AM interviewed the MDS coordinator and inquired about the change that R4 had, inquired if this was a decline in bed mobility or if this was a coding error. MDS coordinator stated that she would follow up with floor staff and let me know. 07/12/18 03:21 PM MDS coordinator stated that this was a coding error on her part and that she would submit a modification for the 04/30/18 MDS. | 2020-09-01 |
| 49 | 49 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 241 | D | 0 | 1 | U50511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. Dignity also means interactions with residents such that facility staff carry out activities that assist the resident to maintain and enhance their self-esteem and self-worth. This facility failed to ensure staff responded in a timely manner to a resident's request for assistance for 2 of 31 residents (Resident #183 and Resident #171) in the Stage 2 sample. Findings include: 1. Resident #183 was admitted to the facility as a short stay resident and was receiving skilled rehabilitation services. During an interview with Resident #183 on 10/26/16 at 8:07 AM, they stated, To be perfectly honest, I think they are short staffed. I get up to use the bathroom, but I'm not allowed to get up by myself because of my fracture and they don't want me to fall. And I don't want to have accidents either, but sometimes, I wait, and I wait, and I wait, and I've had a couple of accidents--yes, shi-shi (urine) or bowels, either one. They said because they couldn't wait for staff to attend, they get out of bed, when I'm really desperate. Resident #183 said because of the long wait times, they have had four accidents. When asked how staff responded when they had these accidents, they said, Not especially anything and I tell them, oops sorry. A lot of times, it's right at the toilet and I can't get there fast enough and I know it's coming. When you gotta go, you gotta go, and they're not here for me. They're busy elsewhere, which is understandable, a lot of other people are here. They're very nice here, don't get me wrong. But, whether it's the early morning, late at night, sometimes there's not enough of them and that's the only reason why I think they're short handed. During an interview with the MDS-C on 10/27/2016 at 1:28 … | 2020-09-01 |
| 50 | 50 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 272 | D | 0 | 1 | U50511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical review (EMR) and staff interviews, the facility failed to ensure that 1 of 31 residents (Resident #90) on the Stage 2 resident sample list, received a comprehensive assessment as part of an ongoing process to identify mood and behavioral symptoms and psychosocial well-being, Also, documentation of assessment information in support of clinical decision making was not found. Findings include: On 10/26/2016 at 07:59 AM, reviewed Resident #90's physician orders [REDACTED]. The resident was prescribed antidepressants and anti-anxiety medications and was sampled for unnecessary medications for Stage 2 of the survey. On 10/26/2016 at 4:00 PM, further EMR review on Resident #90 noted on the facility's PharMerica Resident Change in Condition MRR Request Form, a request to change Resident #90's antidepressant medication due to the resident exhibiting inappropriate sexual behaviors. The form documented: Status change: Increased sexual behaviors, touching self inappropriately in public. Resident kissed another resident. Diagnosis: [REDACTED].>Current medications: [REDACTED] Possible contributing medications: [REDACTED] Name medication regimen is not thought to directly contribute to inappropriate sexual behaviors. however, __ may benefit from a change in therapy (see below). Pharmacy recommendation: Changing Name [MEDICATION NAME] ER 50 mg once daily to [MEDICATION NAME] may provide continued therapeutic benefit for treatment of [REDACTED]. Please consider decreasing [MEDICATION NAME] ER to 50 mg by mouth once every other day x 3 doses. Then start [MEDICATION NAME] 10 mg by mouth once daily x 7 days then increase to [MEDICATION NAME] 20 mg by mouth once daily thereafter. Pharmacist Signature: Name Date: (MONTH) 13, (YEAR). On 10/27/2016 at 8:20 AM, interviewed LN#3 and asked them to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 acc… | 2020-09-01 |
| 51 | 51 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 278 | D | 0 | 1 | U50511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on EMR review and staff interview the facility failed to ensure that the assessment for urinary continence was accurately reflected for 1 of 31 residents (Resident #99) sampled on the Stage 2 Sample Resident List. Findings include: On 10/27/2016 at 3:08 PM the EMR review for Resident #99 found that the resident's minimum data set (MDS) 3.0 on admission date of [DATE], coded urinary continence as frequently incontinent (code 2). By the 90 day quarterly review assessment on 09/06/2016, Resident #99 was coded for always incontinent (code 3) for urinary continence. On 10/28/2016 at 8:23 AM conducted an EMR review on Resident #99 for decline in urinary continence. The progress notes dated 06/03/16 documented that Resident #99 was alert, pleasantly confused, able to follow simple instructions, denied pain and discomfort, incontinent of bladder. The evening shift on 06/03/2016 also documented that Resident #99 was incontinent of bladder. On 10/28/2016 at 9:19 AM interviewed the MDS-Co-ordinator and they accessed the EMR documentation on 06/03/2016 where the RN wrote that the resident is incontinent. The MDS-Co-ordinator looked at the CNA flowsheet and found that Resident #99 was continent only first couple of shifts but incontinent thereafter. Discussed discrepancy of nurses progress notes and CNA flowsheet documentation. The MDS-Co-ordinator stated that the CNA's will be receiving training in coding and probably coding error for urinary continence, as coded frequently (2), and should have been always incontinent (3) from admission. | 2020-09-01 |
| 52 | 52 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 323 | D | 0 | 1 | U50511 | Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews and policy and procedure review during the recertification survey, the facility failed to ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Finding include: On 3/7/16, an IR was filed with the SA regarding Resident # 68 who sustained an unwitnessed fall in the shower room on 3/4/16. The IR documented that Resident #68 was found laying on floor with their head up against (BR) bathroom wall. Resident #68 complained of left ribcage pain and bilateral hip pain. On 3/5/16, radiology department notified facility of left rib fracture. On 10/27/16 at 7:26 AM, Resident #68's Electronic Health Record review (EHR) and concurrent review with the Minimum Data Set Coordinator (MDS-C) dated 4/6/16 was done. In Section C. Cognitive level noted the resident scored a 4 on the Brief Interview for Mental Status (BIMS). According to the Centers for Medicare Services' Resident Assessment instruction (RAI) Version 3.0 manual, the BIMS is a brief screener that aids in detecting cognitive impairment 13-15: cognitively intact: 8-12: moderately impaired; 0-7 severe impairment. 10/27/16 at 7:31 AM, EHR review reveals a careplan with fall prevention interventions stating: 1) Provide one assist with stand pivot transfers from bed to wheelchair. 2) Check on Resident #68 frequently while resting in bed or while up in wheelchair. 3) Ensure laser alarm in place, on and functioning at all times when Resident #68 is in bed and care is not being given. 4) Ensure bedside mattress in place. 5) Assess for dizziness and allow to rest approximately 2-3 minutes prior to transfers from sitting to standing position. 6) Assess for side-effects of Mirtazapine use (twitching, abnormal thinking, restlessness, nausea, dizziness) and notify MD PRN. 7) Keep floor clean, dry and free of … | 2020-09-01 |
| 53 | 53 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 371 | D | 0 | 1 | U50511 | Based on observation and staff interview, the facility did not store, prepare, distribute and serve food under sanitary conditions. Finding include: On 10/25/16 at 8:00 AM, an initial tour with the kitchen manager (KM) revealed an expired quart of yogurt in the entrance refrigerator. The date opened was labeled 10/18/16. KM stated that once food item opened, it is labeled with the date opened and will have an expired date within three days. The yogurt had been expired for four days. On 10/28/16 at 10:00 AM, inspection of the Kona 2 snack and nourishment room revealed an expired 1/2 gallon orange juice container. Staff acknowledged the expiration date and threw away the carton immediately. In summary, the facility failed to store food under sanitary conditions. | 2020-09-01 |
| 54 | 54 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 441 | D | 0 | 1 | U50511 | Based on observation and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Findings include: Observation of a medication pass for Resident #130 was done on 10/27/2016 at 6:45 AM with licensed nurse #4 (LN #4). LN #4 said they were going to test the resident's blood sugar and took out a glucometer from their clothing pocket, saying we share it and placed the glucometer directly onto the resident's blanket. After the testing was done, LN #4 sanitized their hands, grabbed the glucometer and returned it to the cart. The glucometer had not been sanitized yet, but was placed atop the clean medication cart. LN #4 sanitized their hands again, then pulled a Sani cloth wipe and proceeded to wipe the glucometer and placed it back onto the same spot atop the medication cart. Per interview with LN #4, they acknowledged there was a breach in infection control as they had kept the glucometer in their pocket, laid it on the resident's bed and returned it to the clean medication cart without having sanitized it before placing it down. LN #4 said they were kinda new to all this but understood the cross-contamination observed. On 10/27/2016 at 10:32 AM, during an interview with the Resident Care Manager (RCM #1), they verified it was not their practice for licensed staff to leave the glucometer in their clothing pocket. RCM #1 validated it is an infection control issue as to how LN #4 performed it, and they should have used a separate small plastic container to hold the glucometer/supplies for blood sugar checks. RCM #1 also acknowledged the potential for transmission of disease with the way the glucometer was placed on the resident's bed to the clean cart without being wiped down first. | 2020-09-01 |
| 55 | 55 | GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER | 125004 | 3-3420 KUHIO HIGHWAY, SUITE 300 | LIHUE | HI | 96766 | 2016-10-28 | 514 | D | 0 | 1 | U50511 | Based on staff interviews and EMR reviews the facility failed to ensure that the clinical record for 1 of 31 residents (Resident #90) on the survey Stage 2 sample resident list, had enough record documentation for staff to conduct care programs and to manage the resident's progress in maintaining or improving behavioral and psychosocial status. Findings include: On 10/27/2016 at 8:20 AM, interviewed LN #3 and asked then to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 accessed the resident's Behavior Monitoring Log on the EMR which documented, Behavior #1 masturbating in Makai lobby, and on 10/02/2016 the behavior log was marked with 1, and N/A in the Interventions column. The LN #3 went to the EMR Notes tab and could not find any corresponding progress notes on 10/01/2016. On 10/27/2016 at 8:50 AM interviewed RCM#3 to access the EMR. Asked RCM#3 to verify behavior log documentation on 10/02/16, and RCM #3 was not able to find any progress notes in the EMR to corroborate with the behavior monitoring log. The RCM #3 stated that the nurse on that date during evening shift would know what happened. Queried RCM #3 if the staff that observed Resident #90 kissing another resident made an incident report, and RCM #3 stated that there were no progress notes on the incident on 10/02/2016 but that social worker (SW) services may have the documentation. On 10/27/2016 at 9:56 AM interviewed social workers (SW), and both SWs stated that they investigated the incident of Resident #90 kissing a female resident after being informed by LN #4. According to both SWs, Resident #90 was interviewed and counseled about inappropriate behavior of kissing female resident in the TV lobby. When asked for documentation of SW interviewing and counseling of residents on the incident and inappropriate sexual behaviors, both SWs had none to provide. Both SWs stated that they developed a care plan (CP), to address Resident #90's inappropriate behavior… | 2020-09-01 |
| 56 | 56 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 156 | E | 0 | 1 | 8L5Q11 | Based on observation and interviews with resident and staff member, the facility failed to ensure names, addresses and telephone numbers of all pertinent State and advocacy group is posted in a form and manner accessible to residents and resident representatives. Findings include: The resident council interview was done on the afternoon of 10/25/17. The resident representative identified a staff member as the Ombudsman and was not aware the State Agency could be contacted for complaints. Inquired where the posting is located, the representative pointed to the side of nursing station, stating there is a bulletin board located there with the information. Observation found there is no bulletin board for the residents outside of the nurses' station. Further observation found two bulletin boards, one located on the wall outside of the Weinberg Family room and a second bulletin board on a wall outside of the social services office. The information for the telephone number and address of the State Agency was printed on an 8-1/2 by 11 inch paper and tacked on the second row of the information posting. The print and placement were noted to make it difficult for a resident seated in a wheelchair to review. On 10/25/17 at 4:00 P.M. concurrent observation and interview was conducted with Staff Member #324. Staff Member #324 confirmed there are two bulletin boards in the entire facility. The staff member confirmed the information posted on both boards would be too high for residents in wheelchairs to view the information. The staff member also acknowledged the print was small which would be difficult for residents with visual impairment and/or seated in the wheelchair to read. | 2020-09-01 |
| 57 | 57 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 241 | D | 0 | 1 | 8L5Q11 | Based on interviews the faility failed to ensure residents were treated in a respectful and dignified manner for one out of 26 Stage 2 residents. Findings: During an interview with Resident # 98's husband on (MONTH) 23, (YEAR) he stated that staff #-- quite often would speak to his wife and himself in a disrespectful manner. He went onto say this has occured on many occassions and that he and his wife find the manner in which they are spoken to by staff #-- offensive. He also stated he would ask staff #-- to do things for his wife in a particular manner and that staff #-- would not do so. He used an example of asking staff #-- to fold the blanket down on his wife's bed in a particluar way so that it was easy for her to pull it up when she needed it. Staff # --proceeded to fold the blanket into a small square and place at the end of her bed that would make it difficult for her to reach when she needed it. During another interview with Resident #98's husband on (MONTH) 25, (YEAR), he continued to express his concerns about staff #-- manner in which he speaks to both himself and his wife and the blanket incident. | 2020-09-01 |
| 58 | 58 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 242 | D | 0 | 1 | 8L5Q11 | Based on interviews with residents and staff members, the facility failed to ensure a resident has a right to make choices about aspects of his or her life that are significant to the resident for 3 (Residents #53, #248 and #180) of 15 residents interviewed. Findings include: 1) On 10/23/17 at 1:15 P.M. an interview was conducted with Resident #248. The resident was asked whether she is able to choose how many times a week a bath or shower is provided. The resident responded she receives showers twice a week, Mondays and Thursdays. Resident #248 clarified her preference would be for three times a week. A record review was completed on 10/26/17 at 8:15 [NAME]M. A review of the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 2/16/17 notes in Section F0400. Interview for Daily Preferences, Resident #248 reported it is very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's care plan for Activities of Daily Living Assistance notes the resident prefers a shower. A subsequent quarterly MDS with an ARD of 8/17/17 documents, Resident #248 yielded a score of 13 (cognitively intact) when the Brief Interview for Mental Status was administered. On 10/25/17 at 10:00 [NAME]M. an interview was done with Staff Member #114. Inquired how the facility determines the frequency of showers a resident receives. The staff member reported during the first family meeting the facility offers showers twice a week and bathing frequency is discussed. The families are asked how often the resident received showers at home or the resident will be asked if they want more showers. The staff member also reported families and residents are periodically asked about the frequency of showers, usually during the quarterly assessments. On 10/26/17 at 8:20 [NAME]M. Staff Member #113 was asked to provide documentation of the discussion related to frequency of showers during the admission and subsequent quarterly review. Subsequently an interview was done with the Assistant Director of Nursing (A… | 2020-09-01 |
| 59 | 59 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 329 | D | 0 | 1 | 8L5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview and facility policy review, the facility failed to ensure that the medication regimen for one of five residents, Residents #234, was closely monitored for mood and behaviors. Findings include: Resident #234 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #234 had a physician's orders [REDACTED]. The facility did not provide routine mood and behavior monitoring for Resident #234, making it unclear why he was receiving an antipsychotic medication. A review of Resident #234's medical record on the afternoon of 10/25/17 revealed no documentation of behaviors in the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/8/17 (Admission). A review of the nurse's notes did not find notes titled Behavior or any documentation that indicated he was experiencing mood/behavior issues. Additionally, the facility was not routinely monitoring Resident #234's behaviors. On the afternoon of 10/25/17, a review of a form titled, Behavior Monitoring, dated 10/19/17 revealed Resident #234: Did not display moods during the monitoring period; No behavior symptoms displayed during the monitoring period; Resident was currently taking [MEDICAL CONDITION] medications to address mood/behavior symptoms; Current medications are effective in alleviating mood and/or behavior symptoms; No [MEDICAL CONDITION] side effects observed during the monitoring period; There's a current plan of care with intervention to address the resident's mood and/or behavior symptoms; The interventions in place are effective for the resident's mood and/or behavior symptoms. The form further noted the monitoring frequency was to continue weekly monitoring. The rationale for monitoring frequency was left blank. An interview of Staff #46 on the afternoon of 10/25/17 at 3:53 P.M. found Resident #234 had been transferred to his current unit from another unit in the facility on 10/17/17. Staff #46 reporte… | 2020-09-01 |
| 60 | 60 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 371 | E | 0 | 1 | 8L5Q11 | Based on observations and staff interviews the facility failed to ensure proper food handling practices to prevent the outbreak of foodborne illness. Findings include: On 10/23/2017 at 10:15 AM during the initial kitchen tour with Staff#163, observed that the bread storage rack had brown plastic trays to place the bread loaves on and the brown racks were discolored with blackish residue. According to Staff#163 the bread company provided the bread rack and can probably provide a new rack. The walk-in refrigerator #4 contained 4 packages of sliced Swiss cheese with expiration date of 10/07/17 and cole slaw and creamy Italian dressing with no expiration dates. Staff#163 removed the items at that time. The facility did not follow food handling practices to prevent the outbreak of foodborne illness. | 2020-09-01 |
| 61 | 61 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 431 | D | 0 | 1 | 8L5Q11 | Based on observations, staff interview and facility policy review, the facility failed to properly label and store medications. Findings include: During a review of medication storage on two of the six units in the facility on the morning of 10/25/17 at 10:43 [NAME]M. found multiple bottles of medications which were incorrectly labeled and/or stored: 1) Artificial Tears Solution which noted it was opened on 8/10/17. Staff #80 reported the facility's policy was to discard eye drops 60 days after it was opened (10/10/17). Additionally, the medication was discontinued on 9/1/17 but the bottle was still being stored in the medication cart. 2) Artificial Tears Solution which was opened on 10/6/17. The pharmacy label covered the bottle's expiration date and the label did not contain an expiration date. 3) Artificial Tears Solution with a label which noted the prescription was filled on 7/24/17. Staff #80 reported the bottle had been opened but the opened date was not written on the bottle. Staff #80 was unsure of when the bottle should be discarded. 4) Artificial Tears Solution which was opened on 9/12/17. The pharmacy label was blank as though the words were rubbed off - no name, medication name or prescription fill date could be visualized on the label. The manufacturer label noted the expiration date of 2/2020. 5) Artificial Tears Solution which was opened on 10/25/17 but the expiration date of the medication was covered by the pharmacy label. 6) Dorsolamine HCl Ophthalmic Solution with a pharmacy label which was blank as though the words were rubbed off. Additionally, the eye drops were opened on 8/16/17 indicating an expiration of 10/16/17, 60 days since opened. 7) Artificial Tears Solution which was opened on 9/17/17. The pharmacy label covered the bottle's expiration date. 8) Haloperidol 1mg tab which was individually wrapped and did not contain a label. The expiration date was 5/2017. 9) Tuberculin PPD Solution which was opened on 9/18/17 was found in the medication refrigerator. Staff #80 noted that PPD Soluti… | 2020-09-01 |
| 62 | 62 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2017-10-26 | 469 | E | 0 | 1 | 8L5Q11 | Based on observation, interview with resident and staff members and review of the facility's invoices and e-mails, the facility failed to ensure the maintenance of an effective pest control program. Findings include: On 10/23/17 at 1:27 P.M. while standing in the hallway outside of Room 148, a staff member was observed to stomp his foot on the ground, kick something on the ground toward the bathroom and began talking to the Resident #287. The staff member then walked over and picked something off the floor with a paper towel. The staff member was heard informing the resident that he killed a cockroach. Subsequently an interview was done with Resident #287. The resident replied negatively regarding cockroaches; however, reported there are a lot of lizards on the ceiling above her and has concerns that they may fall on her while she is lying in bed. Throughout the survey (10/23/17 through 10/26/17) ants were observed to be crawling on the conference room table. On 10/26/17 at 11:55 [NAME]M. an interview and walk through the facility was done with Staff Member #365. The staff member reported the facility has a contract for pest control. The contractor will come in quarterly for maintenance; however, Staff Member #365 does not keep track/log of when the contractor provides quarterly maintenance. Staff Member #365 also reported the facility will call their contractor if there are concerns. The staff member stated he was not aware of lizards in the facility. The staff member was agreeable to review and provide invoices and e-mails that document that quarterly maintenance (pest control) services were provided by the contractor. On 10/26/17 at approximately 12:30 P.M. Staff Member #365 provided invoices documenting the following: quarterly pest control and rodent control on 9/12/17; rodent control trapping on West Wing Nursing Station on 1/4/17; rodent control trapping, day health on 1/4/17; and quarterly pest control and quarterly rodent control on 12/8/16. A review of the e-mails provided found services were provided o… | 2020-09-01 |
| 63 | 63 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 561 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with resident, the facility did not promote a resident's right to make choices regarding personal hygiene (shaving) for 1 (Resident 162) of 2 residents sampled. Findings include: On 11/20/19 at 11:30 AM an interview was conducted with Resident (R)162. During the interview, R162 was observed to be unshaven. The resident had short hair stubbles on cheeks, chin and over the lip. R162 was asked if facial hair is his preference. The resident responded, no, clarifying staff members shave him twice a week when he receives a shower. R162 further explained that he would prefer to shave himself as there are times when staff members cut him by the lip, chin and under his chin while shaving him. R162 also reported he receives a shower twice a week (Tuesday and Friday) but wouldn't mind showering more often. A record review found a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/28/19 documenting R162 is independent for cognitive skills for daily decision making regarding tasks of daily life. R162 is also noted to require extensive assist with one person physical assist for personal hygiene (how resident maintains personal hygiene, including shaving). R162 also requires one person physical assist for part of bathing. A review of the annual/comprehensive MDS with an ARD of 05/13/19 notes for the resident's preferences for customary routines and activities, R162 rated choosing between a tub bath, shower and sponge bath as very important. The care plan for activities of daily living notes R162 will participate with combing his hair, shaving and cleaning dentures daily. The intervention includes providing sufficient time for the resident to complete bathing, dressing and performing personal hygiene, as well as, providing adequate rest periods between activities (especially after receiving [MEDICAL TREATMENT] treatment). | 2020-09-01 |
| 64 | 64 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 568 | E | 0 | 1 | 6SOG11 | Based on interviews with resident and staff members, the facility failed to establish a process/system to ensure residents with personal funds are actually provided with their financial statements. At the time of survey, there was 102 residents with a personal fund account. Findings include: On 11/20/19 at 11:30 AM an interview was conducted with Resident (R)162. R162 affirmed he has a personal funds account with the facility. Further queried whether he receives a quarterly statement from the facility. R162 responded he does not receive statements from the facility notifying him of how much money he has in his account. The resident speculated he may have about a hundred dollar in his account but not sure. On 11/26/19 at 09:20 AM an interview was conducted with the Financial Controller (FC) and Business Office Clerk (B[NAME]). The B[NAME] confirmed R162 has a personal funds account. Inquired how often does the facility provide statements to the residents? The B[NAME] replied the residents are provided with monthly statements. Further queried what is the process for providing the statements to the residents. The B[NAME] responded, the business office will print the statements, the statements are provided to social services to disperse, then social services will deliver the statements to the units and the unit clerks will provide the statements to the residents. And for those residents that have a representative, the statements are mailed to the representative. The business office does not have documentation/log that the resident actually received their statements. The business office provided a listing of all residents with personal funds. There are 102 residents with accounts. A review of R162's statement for 09/01/19 through 09/30/19 documents he has more than a hundred dollars in his account. The statement lists the facility address for this resident and does not indicate the statements are mailed to a representative. On 11/26/19 at 09:33 AM an interview was conducted with Social Services (SS) staff member. Inqu… | 2020-09-01 |
| 65 | 65 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 640 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to successfully transmit data within 14 days of discharge for Resident (R)1. Findings include: On [DATE] at 02:18 PM a record review was done for R1. R1 was admitted to the facility on [DATE] from an acute hospital. R1 expired on [DATE] and there was no Minimum Data Set (MDS) assessment submitted over 120 days. There is documentation in the electronic health record a MDS was done on [DATE]; however, there was no evidence the discharge assessment was transmitted. On [DATE] at 02:32 PM, an interview and concurrent record review was done with the Resident Assessment Assistant (RAA). The RAA confirmed the assessment was done; however, was not successfully transmitted. | 2020-09-01 |
| 66 | 66 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 641 | D | 0 | 1 | 6SOG11 | Based on record review and interview with staff members, the facility failed to accurately reflect a resident's status for skin conditions. Findings include: Cross Reference to F684. A review of the facility matrix provided by the facility found Resident (R)93 was identified with a facility acquired pressure ulcer. A review of the comprehensive Minimum Data Set (MDS) with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a stage 3 pressure ulcer. The documentation from the facility's private supply vendor assessed R93 was a stage 3 pressure ulcer. Further record review and interview with staff members found R93 has a wound to the left inner buttock, which is not a stage 3 pressure ulcer. | 2020-09-01 |
| 67 | 67 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 658 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with facility staff, the facility failed to meet professional standards of quality. Observation of two medication carts found each cart with one pill splitter with residual pill powder from unknown medications. As a result of this deficiency, residents were placed at risk of experiencing a potential adverse outcome, due to resident's allergies [REDACTED]. Findings include: On 11/22/18 at 09:20 AM, observed medication pass on one of four units. Each medication cart contained a medication pill splitter. Observed medication powder residue on the inside compartment (the area pill is secured, blade for splitting the medication, and the internal compartments) for both medication pill splitters stored on the medication carts. Licensed Practical Nurse (LPN)13 and Registered Nurse (RN)17 both confirmed the pill splitter was used to split various medications for multiple residents. RN17 and LPN13 confirmed the residual pill powder on the pill splitter poses a potential risk to residents and should have been cleaned. LPN13 and RN17 could not confirm the standard professional method used to properly clean the pill splitter to avoid a potentially harmful situation for a resident. An interview on 11/23/19 with the Director of Nursing (DON) confirmed the pill splitter should be cleaned with soap and water after each use. | 2020-09-01 |
| 68 | 68 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 684 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident (R)93 with a wound was accurately assessed and based on the assessment, determine appropriate treatment and interventions for healing and prevention of further skin breakdown to maintain his highest practicable physical well being. The wound reportedly was erroneously assessed as a stage 3 pressure ulcer. The facility also failed to coordinate and provide continuity of care for R93 as evidenced by observation of not applying the heel lift boot at all times; using a half sheet to pull resident up to reposition (creating shear and friction); not following recommendation of the Advanced Practice Registered Nurse to place resident on right side while in bed, not having an OTC ([MEDICATION NAME]) available for treatment, and lack of interventions to decrease moisture while in the facility and during [MEDICAL TREATMENT] treatment. Findings include: Cross Reference to F641. Resident (R)93 was admitted to the facility on [DATE]. R93's [DIAGNOSES REDACTED]. R93 has history of skin breakdown to his right buttock, excoriation to the scrotum and also to his right outer ankle. R93 was identified on the facility matrix with a facility acquired pressure injury. A review of R93's comprehensive Minimum Data Set with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a Stage 3 pressure ulcer, this pressure ulcer was not present upon admission/entry or reentry. On 11/25/19 at 01:33 PM the facility provided a copy of the Care Area Assessment (CAA) which was signed by Resident Assessment Coordinator (RAC)1 on 11/17/19. A review of the CAA notes R93 with a stage 3 pressure ulcer to the left buttock that initially started as shearing, but worsened. R93 noted to be incontinent of bowel and bladder, utilizing briefs to manage incontinence. R93 also requires extensive assistance with one to two person s… | 2020-09-01 |
| 69 | 69 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 689 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to identify potential accident hazards for the following: on two units the housekeeping and supply closets were not secured and supplies on delivery cart were not secured. As a result of this deficient practice, the facility put the safety and well-being of the residents at risk for accident hazards. Findings include: 1) During an observation of the Gardenia Neighborhood Nursing Unit on 11/21/19 at 08:42 AM, a housekeeping closet door was not secured. The closet contained various cleaning solutions including OxyFect H Peroxide disinfectant cleaner and Clorox germicidal bleach. Resident (R)182 was seen propelling self with his/her wheelchair near the unsecured closet and there was no staff in the immediate vicinity. R182 was admitted to the facility on [DATE]. A review of R182's Minimum Data Set (MDS), comprehensive assessment, with an assessment reference date (ARD) of 11/03/19 showed the Brief Interview for Mental Status (BIMS) score was 9 (nine) which indicates that R182 has moderately impaired cognition. During staff interview with the Housekeeper (HSKPR)1 on 11/21/2019 at 10:40 AM, HSKPR1 stated that the housekeeping closet door should be secured at all times. HSKPR1 also revealed that the door has to be pushed a little harder in order for it to close completely. 2) During an observation of the North Neighborhood Nursing Unit on 11/21/19 at 11:00 AM, a central supply closet was not secured. The closet contained various supplies including Sani-cloth germicidal disposable wipes, [MEDICATION NAME] shampoo gel, Purell hand sanitizer foam, and Attend briefs. Resident (R)32 was seen propelling self with his/her wheelchair near the unsecured closet and there was no staff in the immediate vicinity. R32 was admitted to the facility on [DATE], a review of the MDS, quarterly assessment, with an ARD of 03/09/17 showed the BIMS score was 3 (three) which indicates that R32 has severely imp… | 2020-09-01 |
| 70 | 70 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 690 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with facility staff, and record review, the facility failed to provide appropriate catheter care and monitoring of the catheter tubing for sediment build up/clotting for Resident (R)159. As a result of this deficiency, R159 is placed at an increased risk for further complications and infection related to the use of a foley catheter. Findings include: R159 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 11/19/19 at 11:20 AM, initially observed small clots and sediment in the resident's catheter tubing. Observed the catheter tubing on six (6) subsequent days (11/19/19 at 01:03 PM; 11/20/19 at 10:10 AM; 11/20/19 at 12:51 PM; 11/21/19 at 09:28 AM; 11/21/19 at 12:45 PM; and 11/22/19 at 09:45 AM). Each day there was an increase in number of visible small clots and in the size of the build-up of sediment in the tubing. On 11/22/19 at 10:10 AM, observed the catheter tubing with registered nurse (RN)17. RN17 confirmed the catheter tubing and bag should be changed due to the number of small clots, sediment visible in the catheter tubing, and the possible obstruction of urine flow. On 10/23/19, R159 was diagnosed with [REDACTED]. Subsequently, on 10/24/19 R159 was diagnosed with [REDACTED]. R159 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of R159's Minimum Data Set (MDS), Assessment Reference Date (ARD) of 10/27/19, documents R159 is totally dependent on staff for all care including bed mobility, transferring (bed/wheelchair), personal hygiene, dressing, eating, and toilet use. On 11/22/19 at 09:11 AM, observed certified nurse aides (CNA)21 and CNA3 provide catheter care to R159 due to fecal incontinence. CNA21 wiped R159's perineal area (soiled with feces) with a disposable wipe then used the same disposable wipe to clean the right labia majoria. The disposable wipe was visibly soiled with feces. The facility's policy and procedure, Catheter Care, instructs staff to not contaminate … | 2020-09-01 |
| 71 | 71 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 692 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff members, the facility failed to ensure 1 of 3 residents was monitored for weight loss. The system for reporting significant weight loss for a resident receiving daily weights was not established; therefore, the resident was not assessed by a Registered Dietitian (RD). Also, the facility failed to develop a care plan to address weight loss related to the resident's [MEDICAL CONDITION] and use of diuretics. Findings include: Resident (R)209 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 11/19/19 at 2:30 PM an interview was done with R209. R209 reported loosing weight, approximately 4 to 5 pounds. Further inquired whether she was on a special diet, she replied no. Observation also found R209's lower extremities were mottled with red spots and appeared to be swollen. R209 reported she fell at home and the red spots were the result of [MEDICAL CONDITION] crawling on the carpet. On 11/20/19 at 09:15 AM R209 was observed sitting outside of her room and had eaten all her breakfast. R209 stated breakfast is the best meal. Record review found the following weights for R209: 166 (11/01/19); 163 lbs. (11/06/19); 159 lbs. (11/13/19); 153 (11/14/19); 148 (11/19/19); 145 (11/21/19) and 143 (11/25/19). On 11/01/2019, the resident weighed 166 lbs. and on 11/25/2019, the resident weighed 143 pounds which is a 14% weight loss in less than a month. A review of the physician's orders [REDACTED]. twice daily for generalized [MEDICAL CONDITION]. The admission Minimum Data Set with an assessment reference date of 11/06/19 notes R209 did not have a weight loss and indicates R209 received diuretics during the assessment period. A review of the Comprehensive Nutritional Assessment, signed 11/11/19 notes the following diet recommendations: 3 gram sodium; regular texture; and fluid restriction. R209 also noted to have fair to good intake at meals with 2+ [MEDICAL CONDITION].… | 2020-09-01 |
| 72 | 72 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 755 | D | 0 | 1 | 6SOG11 | Based on staff interview and a review of facility records, the facility failed to document the narcotic count log on 1 of 4 units. As a result of this deficiency, there is a risk of potential diversion of controlled medications. Findings include: On 11/22/19 at 09:30 AM, a review of the narcotic log on one of four units found the narcotic log was not completed. On 11/19/19, the off-going (night shift) and the oncoming (day shift) failed to complete the narcotic log. The staff did not document the number of actual narcotic medication counted between the shifts; however, as evidenced by their initials, they attested to the count (which was blank). A review of the individual narcotic count sheets for every resident notes a total of 5 of 11 medications were administered. Licensed Practical Nurse (LPN)25 confirmed, the facility utilizes the narcotic log as part of a three-check system to count and account for narcotic medications. The count on the narcotic log is used at the change of each shift. One licensed nurse from the off-going and the licensed nurse coming on duty reconcile the narcotic log against the actual narcotic medication (tablets, solutions, patches) stored in the narcotic drawer and the resident's individual narcotic sheet. LPN25 confirmed the narcotic log should not be left blank. | 2020-09-01 |
| 73 | 73 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 756 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure the attending physician responded to the pharmacist's recommendation regarding the use of an antipsychotic medication ([MEDICATION NAME]) for Resident (R)137. As a result of this deficiency, R137 could potentially experience adverse outcomes and may not be receiving the lowest possible dose with the most benefit. Findings include: A record review found a progress note, 04/27/19 at 09:39 AM by Pharm1 documenting a Drug Regimen Review (DRR) was completed. Pharm1 documented, R137 has been receiving an antipsychotic [MEDICATION NAME] 0.25 mg QAM (every morning) and 0.5 mg QPM (every night) since 10/21/18. Pharm1 requested the attending physician complete an evaluation of the current dose and to consider a gradual taper of the dose to ensure (R137) is receiving the lowest possible effective/optimal dose. There was no documentation of the pharmacist's report to the physician regarding use of [MEDICATION NAME] or a response from the physician. A subsequent review by the pharmacist on 05/30/19 at 09:31 PM, notes the attending physician failed to respond to a previous request for an evaluation/gradual taper of dose for [MEDICATION NAME]. At this time, Pharm1 planned to resend last months note (dated 04/27/19). On 11/22/19 at 08:51 AM, the Assistant Director of Nurses (ADON) was unable to find the 04/27/19 documentation of the correspondence from the pharmacist to the attending physician. The ADON provided documentation which was dated 05/31/19 in which the attending physician responded to the pharmacist. The date of the response is illegible (possibly (MONTH) 2019). | 2020-09-01 |
| 74 | 74 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 758 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to address the gradual dose reduction and use of an antipsychotic to treat a specific condition for 1 of 5 (Resident 189) residents reviewed for unnecessary medication. The facility inconsistently monitored the resident's targeted behaviors for use of [MEDICATION NAME], the targeted behaviors to address the use of [MEDICATION NAME] was changed over a period of time which does not provide accurate monitoring of the targeted behaviors related to the drug usage. Also, the start date of the medication was inconsistent, therefore, there was no documentation by the pharmacist of a recommendation for gradual dose reduction and the pharmacist did not address the increase of the [MEDICATION NAME]. Findings include: Resident (R)189 was admitted to the facility following an acute hospitalization on [DATE]. R189's [DIAGNOSES REDACTED]. R189 also has an indwelling foley catheter. On 11/19/19 during the initial tour, R189 was observed laying in bed asleep. Subsequent observation at 02:14 PM found the resident lying in bed with a pillow between his legs. On 11/20/19 at 09:10 AM, R189 was observed to be asleep in bed with the television on. At 11:30 AM, R189 appeared awake and attempted to screen the resident for appropriateness of interview. R189 attempted to sit up, setting off his clip alarm, a staff member entered the room and he asked whether lunch was coming. Inquired if he was hungry, he replied no. The screening was discontinued. Later stopped in to visit the resident at 02:15 PM, he was lying in bed asleep. A record review done on 11/22/19 at 07:35 AM noted physician orders [REDACTED]. (start date of 07/22/19) at hour of sleep for [MEDICAL CONDITION] with behavioral disturbance; and [MEDICATION NAME] 50 mg. (start date of 06/30/19) twice a day for [MEDICAL CONDITION] with behavioral disturbance. A review of the [MEDICAL CONDITION] medication review found the re… | 2020-09-01 |
| 75 | 75 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2019-11-26 | 761 | D | 0 | 1 | 6SOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to: label the blister back for a blood pressure medication with the correct dose for one Resident (R)47 which would place the resident at high risk for injury due to receiving the wrong medication and/or the wrong dose of medication; appropriately discard an antibiotic ointment medication from the treatment cart (the label was non-readable); and failed to label medications with discharge date s. Findings include: 1) During a medication administration observation with LN52 noted a blister pack for R47, the medication was [MEDICATION NAME] (a medication to decrease blood pressure) give 25 milligram (mg) tab 37.5 mg (1.5 tabs) by mouth (PO) twice per day (BID) Diagnosis: [REDACTED]. A hand written note in black ink was noted on the top left corner of the blister pack that stated direction changed, refer to chart. When asked what the correct dosage for R47 was LN52 stated, the new dose was just changed and the new order states to give 25 mg (1 pill) BID. We were giving 25 mg, 1-1/2 tabs, daily which totals 37 mg. LN52 verified that the dosage was changed and now R47 receives only one 25 mg tab, and the label on the blister pack does not reflect the new dose. Medical record reviewed. The Medical Doctor (MD) order dated 11/02/19 states [MEDICATION NAME] 25 mg tabs. Give 1 tab PO BID. During an interview with LN52 on 11/22/19 at 11:00 AM, discussed the labeled blister pack. LN52 stated that in a situation where the order is changed and the medication is the same but the dosage is changed, normally the new dose is written on the top left corner of the blister pack and highlighted in yellow. The nurses normally don't cross out the old dosage information and will continue to use the medication in the blister pack until it runs out. LN52 further explained, since each blister has 1-1/2 tabs, and the order is now 1 tab, they will use the whole tab, then the half tabs (2) until they a… | 2020-09-01 |
| 76 | 76 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 584 | E | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to have an adequate process in place to ensure mosquito nets installed in several of the resident's rooms in the East and West neighborhoods were adequately maintained, and equipment removed when not in use. As a result of this deficiency, there were several rooms on the east and west neighborhoods that did not have a clean, homelike environment. Findings Include: 1. On 11/27/2018 at 10:47 AM observed several resident rooms in the West Neighborhood had mosquito nets installed. The nets were tied in a knot to keep them from hanging on the floor and pulled to the side of the room. Several other rooms (Rm), Rm 5, Rm 7A, Rm 8B, Rm10A, Rm 10B, Rm 11A, and Rm 14A had a rope/string hanging above the center of the resident's bed. The hanging ropes made the rooms look unappealing and not homelike. Several of the mosquito nets were in poor condition and needed to be replaced or cleaned. Rm 12A was discolored and gray, Rm 13B had multiple holes and Rm 8B had dead insects in the net. During an interview with Registered Nurse (RN)126 on 11/29/2018 at 3:30PM, looked at the mosquito net in Rm 12A and stated that it needed to be taken down or washed. We used the nets when residents were getting bit a lot, but we are not currently using many. That was quite a while ago. If a family requests one, we will put one up. We fill out a work order and maintenance put it up. RN126 stated, I'm not sure who cleans them, housekeeping or maintenance. During an interview on 11/30/2018 at 10:00 AM with the Maintenance and Equipment Coordinator who explained Maintenance does PM (preventive maintenance) on the mosquito nets every six months and we change them out. We don't wash them, we throw them away and put a new one up. It's nursing's responsibility to do a work order to replace it. 2. During a resident interview on 11/28/18 at 08:33 AM observed a small rope hanging over the middle of R183's bed (four … | 2020-09-01 |
| 77 | 77 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 656 | D | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement respiratory care into Resident (R)54 comprehensive person-centered care plan. The deficient practice resulted in the lack of measurable objectives and timeframe's to appropriately evaluate treatment plan for R45's oxygen (O2) therapy. Findings include: During an observation on 11/28/18 at 01:57 PM R54 was in bed on her right side with oxygen (O2) via nasal cannula. The O2 concentrator was set at two liters (L). R54 Respirations were noted to be steady and slightly labored. The minimum data set (MDS) assessment summary dated 11/02/18 was reviewed. R54 was ordered 02 for comfort, and denied any shortness of breath (SOB). R54 is anticipated to decline due to her non modifiable conditions and power of attorney (POA) has agreed to no hospitalization s at this time. Comprehensive care plan reviewed, no respiratory goals or interventions were noted on R54 care plan. During an interview with Registered Nurse (RN)173 on 11/29/18 at 05:01 PM who stated that R54 is declining, we discussed with the family about hospice and they declined. The MD was the Locum and made a note about offering hospice care. The family decided not to have R54 hospitalized . The family is supportive and comes here often. Physician (MD) orders reviewed with Nursing supervisor revealing no orders for O2. Per RN173 on 10/17/18 R54 was declining and thought to be actively dying. The oxygen was placed at that time for comfort. We did not pursue an order for [REDACTED].> | 2020-09-01 |
| 78 | 78 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 657 | D | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to meet professional standards of care that would dictate the care plan be revised/updated to reflect changes in condition and approaches for meeting the needs of two Resident's (R), R44, and R127. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions to promote continuity of care and communication amongst nursing staff to safeguard against adverse events were not identified and documented in a timely manner. Findings Include: RR of R127's medical records revealed that R127 had a reoccurring [MEDICAL CONDITION] of the left thigh. R127's care plan identified the problem at risk for skin breakdown i.e. ulcers, rashes, skin tears, with the goal of extrinsic risk factors for skin breakdown will be reduced or eliminated. 11/15/2018 Physician (MD)1 addendum note for R127, includes: recurrent left upper thigh [MEDICAL CONDITION]/rash of left medial and lateral thigh. The warmth of the room and keeping pt. covered contributes to this .ask if pt (sic) can be kept a little cooler. RR of R127 revealed no evidence of documentation that the care plan had been revised to identify interventions to address the contributing factors to the [MEDICAL CONDITION] (warmth of the room, and keeping the resident covered) identified by MD1. During an interview with RN126 on 11/28/2018 at 02:25 PM who stated, I hadn't seen that entry. Inquired if MD1 had communicated the concern to anyone, and RN126 replied, No, but it should have been in the care plan. RR of R44 revealed a new [DIAGNOSES REDACTED]. There was no evidence of documentation that the care plan for R44 was updated to include appropriate interventions and monitoring to minimize complications related to the Pneumonitis (i.e. shortness of breath, fever, drop in oxygen level). During an interview and RR on 11/29/18 with RN126 who agreed the care plan had not been updated to include the new [DIAGN… | 2020-09-01 |
| 79 | 79 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 689 | D | 0 | 1 | 6SFF11 | Based on observations and interview the facility failed to identify a resident's risk for an accident, including the need for supervision and assistive devices for one of 68 residents ((R)117) in the survey sample. The deficient practice did not provide adequate supervision and professional standards of practice placing R117 at an increased risk for injury. Findings Include: On 11/27/18 at 12:11 AM observed a certified nursing assistant (CNA) 194, pushing R117 in her wheelchair backwards down the hallway. The resident was talking in her native language and appeared agitated at the CN[NAME] Queried CNA194 why R117 was being pushed backwards in the wheelchair. The CNA 194 stated that R117's wheelchair footrests were broken and going forward may cause her feet to be run over. On 11/30/18 at 10:00 AM interviewed the unit's charge nurse (CN) 279 and inquired about R117's broken foot rests. The CN279 stated that residents in wheelchairs should not be pushed backwards, and only if going through a door. The CN279 stated that she will re-educate staff. | 2020-09-01 |
| 80 | 80 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 761 | E | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure six medication labels were properly labeled with discard dates, and one medication remained in inventory beyond the expiration date. The deficient practice had the potential to affect the efficacy of the expired drug, and the timely identification and removal of medications when they are expired. Findings Include: 1. An inspection of the medication room on the West Neighborhood was completed on [DATE] at 09:34 AM. Pharmerica, is contracted to supply all pharmaceuticals except for over the counter medications, which are purchased by the facility. The procedure for both Pharmerica and the facility is to hand write the discard date on the label of the medication container or package. Registered Nurse (RN) 126 was present during the inspection and asked to review the labels for expiration and discard dates. The following did not have discard dates written on the label: One bottle Antacid, one bottle of Polyethylene [MEDICATION NAME] Powder, one package of Nicotine gum, one bottle of [MEDICATION NAME] and one bottle Sentry Multivitamin. 2. The WEST Neighborhood Medication cart number two was inspected on [DATE] at 10:00 AM which revealed the labels of one bottle of [MEDICATION NAME] and one bottle of [MEDICATION NAME] 1 milligram (mg) did not have discard dates. 3. During an observation of the North Neighborhood Medication Cart on [DATE] at 08:56 AM, an expired packet of [MEDICATION NAME] was found in the storage drawer. The label read discard after ,[DATE]. During an interview with Licensed Nurse (LN) 2 on [DATE] at 08:57 AM who acknowledged that the [MEDICATION NAME] packet was expired and should have been removed. The facility policy on disposal of medications was reviewed stating It is the policy and practice of Hale Makua Health Services that all medications that have been discontinued, expired, or require wasting will be identified and removed from the medication supply in a t… | 2020-09-01 |
| 81 | 81 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 812 | E | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure safe food handling processes. The kitchen staff did not ensure proper storage by tracking when to discard perishable food. The deficient practice placed residents at risk for illness. Findings Include: During the initial kitchen tour on [DATE] at 10:27 AM with the director of nutrition services (DNS), found in the kitchen small pantry, an opened case of parmesan cheese packets with expiration date of ,[DATE]. In the produce refrigerator observed a bunch of brown colored celery, and in refrigerator #6 there was a bottle of blackberry puree with an expired date. | 2020-09-01 |
| 82 | 82 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 842 | D | 0 | 1 | 6SFF11 | Based on interview, record and policy review, the facility failed to document the signature date on an Advance Health-Care Directive (AHCD) form for Resident (R) 162. As a result of this deficient practice, the AHCD form would be invalid, and R162 may not have received the care as indicated on the prepared AHCD form. Findings Include: During record review for R162, it was noted that the AHCD form did not contain a date that was required on the form. The AHCD form read Signatures; Sign and date the form here. The section where the date was required contained a signature instead. During an interview on 11/29/18 at 03:04 PM with the Director of Health Information Management (HIM Director), HIM Director acknowledged that the AHCD form was missing the required date. During review of the Facility policy on Advance Directives which stated The Director of Admissions will review any advance directive to be sure it is valid under current law. | 2020-09-01 |
| 83 | 83 | HALE MAKUA - KAHULUI | 125007 | 472 KAULANA STREET | KAHULUI | HI | 96732 | 2018-11-30 | 880 | E | 0 | 1 | 6SFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record and policy review, the facility failed to post a warning sign of contact precautions at the entrance of two resident rooms, Resident (R) 192 and R8's room. The deficient practice put the staff and visitors at risk of contracting R192's known illness of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and R8's active infestation of lice. The facility also failed to ensure direct contact staff demonstrated proper use of gloves with hand hygiene and proper technique for wound care/dressing change. The deficient practice increased R204's risk of illness/ complications of infection. Findings Include: During a record review for R192, revealed the resident had a [DIAGNOSES REDACTED].>During an observation of R192's room, on 11/27/18 at 12:24 PM, several carts were noted to be parked outside the room. One of the carts was yellow, and the other cart was blue and gray. The carts were not marked with a warning sign that would indicate that R192 was on contact precautions. Anyone could have entered the room not knowing that contact precautions were needed. During an interview with Charge Nurse (CN) 41 on 11/27/18 at 12:28 PM, CN41 acknowledged that a warning Sign should have been posted at the entrance of R192's room. Facility policy titled Hale Makua Infection Control Manual for LTC, Contact Precautions was reviewed, it stated At the time a resident is place on Contact Precautions, the Unit Clerk will notify all pertinent departments. Before entering the room of a resident on Contact Precautions, staff and visitors should consult with a licensed nurse for instructions on specific precautions to be taken and Personal Protective Equipment to be used. 2. During an observation on 11/27/2018 at 12:30 PM observed a conspicuous sign outside R8's room that said isolation. The sign did not have any other information (i.e. type of isolation or instructions to report to the nursing station prior to entry) on it. Tw… | 2020-09-01 |
| 84 | 84 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2017-06-02 | 280 | D | 0 | 1 | HXLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and medical record review (MRR) the facility failed to utilize interdisciplinary expertise to improve range of motion (ROM) for 1 of 24 residents (R#129) on the Stage 2 survey sample resident list. Findings include: On 06/01/2017 at 12:13 PM observed R#129 with splint on the right (R) hand. On 06/01/2017 at 12:37 PM, the MRR on R#129 found that a ROM assessment was last done on 4/28/17. The interdisciplinary conference notes included the rehab report for U/E Range of Motion: No changes noted with _R#129's U/E ROM this screen .Resident received U/E ROM 2 x/week on unit since her return from acute hospital. Use of R handroll for contracture management and utensil with build-up handle for facilitating in feeding. The care plan (CP)#2, I am at risk for further decline in ROM d/t impaired mobility secondary to medical problems; with Goals: I will have no further decline in ROM; and interventions included: 6. encourage me to use utensil with build-up handle for feeding; 7. Use right handroll 2-3 hrs every am and pm shift for contracture management. Check for redness or skin breakdown. Discontinued use of handroll immediately if redness or skin breakdown, & notify CN or OT department; 8. maintenance OT/PT programs 2 x/week UE/LE exercises. Behind the CP#2 were instruction sheets for R handroll use with instructions to place handroll on right hand for 2-3 hours every a.m. and p.m. shift. On 06/01/2017 at 2:32 PM observed R#129 sleeping in bed and the handroll was not placed in R#129's hand, but around the wrist. The resident's family member was at the bedside visiting and stated that R#129 cannot stretch fingers & whenever they try to stretch the fingers R#129 complains, sore. The family member also tried to use a pressure ball in the hand but R#129 refused. Queried Staff#59 if the resident's handroll was properly placed and Staff#59 stated that R#129 moved the handroll and sometimes will throw it. On 06/02/2017 at 11:42 AM obse… | 2020-09-01 |
| 85 | 85 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2017-06-02 | 313 | D | 0 | 1 | HXLB11 | Based on record review, resident and staff interview the facility failed to ensure that 1 resident of the 27 Sample Stage 2 residents received proper treatment and assistive devices to maintain their vision. Findings include: On 06/01/2017 at 12:09 PM Resident (Res) #123 was observed eating his lunch without use of glasses. At 12:27 PM interviewed Res #123 and resident stated that they do not use glasses and feels their eyesight is good. On 06/02/2017 at 10:56 AM review of resident's record showed there were no eyeglasses on the property sheet, no care plan for the use of eyeglasses and no mention of the need for eyeglasses in the physical completed by the physician. Interview of staff #4 at that time stated that resident can read without glasses and that resident did not come in with glasses. On 06/02/2017 at 11:30 AM record review of last quarterly MDS, which was completed on 04/21/2017 has the following checked off under vision: Impaired-sees large print, but not regular print in Newspaper/books. Interview of staff #28 shared that the resident's family makes their appointments at the VA and that maybe the daughter could bring in glasses for the resident. At that time Res #123 did not have an eye appointment scheduled. On 06/02/2017 at 11:40 AM interview with staff #65 stated that resident was tested for his vision before it was documented in the MDS and the resident was only able to read the large print on the newspaper and not the small print, the coding was done correctly for Res #123. The facility failed to ensure that the resident receive proper treatment and assistive devices to maintain their vision. | 2020-09-01 |
| 86 | 86 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2017-06-02 | 325 | D | 0 | 1 | HXLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record reviews (MRR), the facility failed to ensure that the physician participated in the nutritional assessment, and that a more in-depth nutritional assessment was done to identify nutrition related risks for 1 of 24 residents (R#129) on the survey Stage 2 sample resident list. Findings include: On 06/01/2017 at 12:03 PM observed R#129 eating lunch in the activity/dining room (rm) on the facility's second floor unit. The resident was able to self-feed the pureed meal served on a divided plate. The resident drank all of the fluids served in 6 ounce plastic cups and also the 1/2 cup of applesauce. After finishing all of the liquids of milk, apple juice, water and pureed applesauce, R#129 started to eat spoonfuls of pureed beef mac casserole and chicken rice soup. The resident was sampled for nutrition due to having a body mass index (BMI) of 18.2 and with no physician ordered supplement. On 06/01/2017 at 1:01 PM the MRR on R#129, found that the 2/7/17 speech/swallowing therapy evaluation for swallowing recommendations were for pureed solids and honey consistency liquids with feeding by nursing to observe for actual swallow. The residents weight (wt) on 5/24/17 was 87 lbs; 5/10/17 was 89 lbs in the units weight book. On 06/01/2017 at 1:05 PM interviewed Staff#24 as noted that the last nutritional assessment was done on 2/1/17 after an acute hospitalization for [DIAGNOSES REDACTED] ulcer perforation when R#129 was on GT feeding. Staff#24 stated that R#129 pulled out his/her gastrostomy tube (GT) on 2/14/17, and was put on intravenous (IV) fluids and pureed diet. The R#129 also pulled out the IV. On 2/15/17 the MD recommended not to replace GT/JT because the resident would continue to pull out tubes and would replace if he/she had poor intake. Since 2/15/17 R#129 received a pureed diet and doing well. Staff#24 stated that registered dietitian (RD) was included on interdisciplinary (IDT) meetin… | 2020-09-01 |
| 87 | 87 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2017-06-02 | 333 | D | 0 | 1 | HXLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that 1 resident of the 27 Stage Two sample of residents was free from significant medication error. Finding includes: On 05/31/2017 at 3:00 PM while reviewing Resident (Res) #95 chart and Medication Administration Record (MAR) a medication error was discovered. Res #95 has a doctor's order written on 04/11/2017 for the following medication [MEDICATION NAME] 70-30 vial, inject 18 U SQ q AM and 6 U SQ q PM, If resident eats 25% or less give [MEDICATION NAME] 70-30 9 U SQ Q AM and 3 U SQ q PM. Hold if BS On 06/02/2017 at 10:42 AM met with staff #28 to discuss medication error that occurred on 05/26/2017. Staff #28 reported that staff #20 discussed medication error with them on 05/31/2017 and they filled out the event report and notified the resident's physician and the physician in turn clarified the order. The facility failed to ensure this resident was free from a significant medication error which could have resulted in an injury to the resident. | 2020-09-01 |
| 88 | 88 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2017-06-02 | 428 | D | 0 | 1 | HXLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews the facility failed to review medications in collaboration with the MD for 1 of 24 residents (R#84) on the Stage 2 survey sample residents list. Findings include: On 06/01/2017 at 8:38 AM the MRR on R#84 found on the (MONTH) (YEAR) physician order [REDACTED]. for the [DIAGNOSES REDACTED]. The facility's pharmacist review dated 5/15/17 noted, 5/3 decrease (drawn arrow pointing down); 5/3 INR 3.1 re-titrate; MD Warfarin update. The lab results for PT/INR done on 5/03/17, had results of , PT 31.8 secs/ INR 3.1. The physician telephone order on 5/3/17 noted, Coumadin 1 mg PO on MWFSS and 2 mg PO on TTH. Check Protime in 1 month. The MD progress notes on 5/18/17 for the recertification visit noted on the, Plan: On coumadin cont medication. Adjust dose as indicated. Q 2 week INR checks .; Medications ordered: Warfarin 2 mg oral tab; Sig - route: Take 1 tablet by mouth once daily on T, TH, Sa, Su and take 1/2 tab on the other days for thinning the blood . Interviewed Staff#24 to clarify discrepancy of Jun 17 PO and MD visit on 5/18/17 with different orders for Warfarin. Staff#24 had to check with the MD as could not find documentation that new order was clarified with MD. MD report was faxed to facility on 5/22/17 12:36:54 AM. The IDT progress notes on 5/28/17 noted that the MD was notified & staff received telephone order for [NAME]itussin DM Q 6 hr for cough as R#84 was coughing/wheezy earlier that day. The residents CP#13, I am at risk for possible SE r/t use of Warfarin, included interventions: 1. Provide medication as ordered. (Warfarin Na). Observe for side effects like bleeding, behavioral changes, skin rashes, etc, document and notify MD as indicated. Lab works as indicated. Notify MD for changes. 3. Check my skin every shift and monitor for early signs of skin breakdown like redness blisters, rashes, bruises or an signs of bleeding, document and notify MD as indicated 5. refer to Pharmacy… | 2020-09-01 |
| 89 | 89 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 578 | D | 0 | 1 | 55H911 | Based on record review and interview the facility failed to complete an advanced health care directive (AHCD) for one of four residents investigated (resident (R)29 ). Findings include: Electronic Medical Record (EMR) for R29 reviewed. No AHCD or documentation that the resident or family representative refused to have an AHCD was found in record. The Maluhia resident's rights and responsibilities and advance directive and decision-making support documentation reviewed for R29. The Family member (FM)1 Advance Directives form checked that R29 does not have an advanced directive and that FM1 would like to have more information about advanced directives. Plan for follow up stated check with social worker. Signed and dated by the Power of attorney and dated 7/01/14. No follow up from the Social Worker (SW) was documented in the EMR. During an interview with the SW23 on 07/11/19 at 12:30 PM stated during the admission process, we will discuss the AHCD with the resident and/ or representative. If they have an AHCD done, we will review it and file it, but if they don't have one they will be given the forms to complete. We will have our notary do it. At the annual Inter-disciplinary team meeting (IDT) we can review it and /or follow up. When R29 was admitted to Maluhia, we completed the intake forms and did not follow up to ensure family was given information on the AHCD. Now moving forward we are addressing the AHCD at the time of admission and annually at the IDT meeting to ensure it was done. | 2020-09-01 |
| 90 | 90 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 584 | D | 0 | 1 | 55H911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide clean bed rails in good condition for one of two residents (R)256 investigated. The deficient practice compromised the infection prevention control for R256 and lacks a homelike environment . Findings include: During an observation of the bed rails for R256 on 07/09/19 at 12:55 PM noted they appeared to have soiled tape wrapped around the rails that contained yellow/ brown residue on the tape. During an interview with the Licensed practical nurse (LPN)21 on 07/12/19 at 09:20 AM , upon review of the taped rails and asked what the tape was for LPN21 responded I am not sure but I will follow up and get back to you. During an observation on 07/12/19 at 09:42 AM the Director of Nursing (DON) and Head Nurse (HN)22 went into room [ROOM NUMBER] with LPN 21. The HN22 responded that the rails are taped because the foam on the rails was peeling off, I will ask maintenance to change it. | 2020-09-01 |
| 91 | 91 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 695 | D | 0 | 1 | 55H911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a resident who needs respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of one residents (Resident (R) 20) selected for review. This deficient practice had the potential to affect the other residents identified by the facility to require [MEDICAL CONDITION] care. Findings Include: On 07/09/19 at 03:33 PM, a random observation of Resident (R) 20 was done. R20 has a [MEDICAL CONDITION] and a care plan for being at risk for respiratory difficulty related to his [MEDICAL CONDITION] (trach) site. R20's care plan states he also requires frequent suctioning 4-6x (times) per day, including suctioning to [MEDICAL CONDITION] as needed for excessive oral secretions, and to assess his respiratory status (i.e., increased respiratory rate). During this observation, R20 exhibited an increased respiratory rate, intermittent gurgling like sounds and had whitish secretions coming out from [MEDICAL CONDITION] onto a napkin placed around [MEDICAL CONDITION]. At that time, the certified nurse aide (CNA) 1 who had taken R20's vital signs was in the hallway along with registered nurse (RN) 3. CNA1 stated she reported R20's status to the on-coming evening shift nurse, RN1, about five minutes prior. CNA1 said she told RN1 that R20 needed to be suctioned and had an increased respiratory rate around like 30 (breaths per minute). RN3 then stated the nursing endorsement can wait at the change of shift and went to find RN1. On 07/09/19 at 03:37 PM, RN1 came to attend to R20 at bedside. She prepped using sterile technique, but had some difficulty donning the gloves since she opened the sterile glove set on the resident's bed, along with [MEDICAL CONDITION]. There was an overbed table to use, but s… | 2020-09-01 |
| 92 | 92 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 726 | F | 0 | 1 | 55H911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the licensed nurses contained documentation that the core competencies were filed in each employees education record. The deficient practice compromised competent nursing care is being provided to all of the residents residing in the facility. Findings include: 1) During an investigation into the competency of one licensed nurse (LN) on 07/11/19 at 03:41 PM it was discovered that the employee competencies for the entire nursing staff were missing from their employee training records. During an interview with the Director of Nursing (DON) on 07/11/19 03:43 PM stated that the employee skills and competency checklists for one licensed nurse were not found. Upon further investigation by the Employee Education coordinator it was discovered that none of the nursing staff had the skills and competency checklists filed in their employee records. The DON added that any training completed by the employee is documented and filed in their personal records. We keep everyone's records in the files until the employee leaves work at the facility. Our legal person drafted an affidavit for the employee in question and was notarized and signed stating that she completed the competency checklist. I told the level asked the level six Registered Nurses have all Licensed Nurses complete the core competency training as soon as possible. Each licensed nurse who could not provide a copy of the core competency check list will complete a notarized affidavit stating the requirements were completed at the time of hire. In the interim, we have already started to re-certify our licensed staff in the competency's and it will take a while. 2) Cross-reference to findings at F695. On 07/12/19 at 10:24 AM, RN2 said if there was anything out of baseline, the licensed staff, need to do a progress note. Even if they did do the suctioning, (only that documentation) looks like just a routine event versus something els… | 2020-09-01 |
| 93 | 93 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 804 | E | 0 | 1 | 55H911 | Based on observation, interview and record review the facility failed to monitor safe temperatures on the steam table during meal preparation. The deficient practice placed residents at risk for food borne illness. Findings include: During an observation of the tray line on 07/11/19 between 11:30 AM to 11:50 AM during the lunch preparation it was noted that dietary staff were serving up the menu items onto trays for individual resident meals for the long term care (LTC) facility, the Adult Day Health Center (ADHC) and Meals on Wheels. The trays were then loaded into carts. Dietary staff did not check the internal temperatures of the beef tomato, peas or rice being served for the lunch time meal. The temperature logs for the steam table were not found. During an interview with the Dietary manager (DM) at 11:50 AM regarding the location of the temperature logs replied the log is kept on the bulletin board and pointed to a large bulletin board on a wall near the walk in freezer. Review of the temperature logs for the steam table revealed a blank temperature log. When asked when do the dietary staff check the temperatures the DM replied the temperatures are checked before and after the tray line and written down later. Observed the DM walk over to the tray area and retrieve a digital thermometer out of the drawer, clean with an alcohol wipe and proceed to the tray line while stating we keep the food really hot then checked the temperature of the beef tomato 190 degrees Fahrenheit (F), and the peas 200 degrees F. Facility Food Temperature Safety guide reviewed. Ground Meats are to be kept at 155 degrees F. The (YEAR) food and drug administration (FDA) food code reviewed. A summary chart for minimum cooking food temperatures and holding times required. Chapter 3 Meats (145 degrees) and 3 minutes holding time required for safe temperatures. | 2020-09-01 |
| 94 | 94 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 842 | D | 0 | 1 | 55H911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review (RR) the facility failed to maintain accurate medical records for one resident (R)85 of 47 sampled residents. Medical records were not updated to reflect the most current diagnoses. There was a discrepancy of active [DIAGNOSES REDACTED]. This deficient practice has the potential to affect all residents. Findings include: 1. R85 was admitted to facility 12/24/09 after acute care hospitalization . Transfer [DIAGNOSES REDACTED]. urinary tract infection, and status [REDACTED]. Hospital course included, [MEDICAL CONDITION]. This patient was treated on her outpatient medication, [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]). 2. A Pre-admission Screening /Resident Review Psychiatric Evaluation Part II Serious Mental Illness (SMI) Criteria (PASRR11) was completed on 06/23/16. The PASARR II revealed the facility marked Yes, to The patient is [AGE] years or older and has a possible [DIAGNOSES REDACTED]., but the PASARR II did not list [MEDICAL CONDITION] as a diagnosis.The [DIAGNOSES REDACTED]. 3. Minimum data set assessment ((MDS) dated [DATE] active [DIAGNOSES REDACTED]. 4. RR revealed one of the current active [DIAGNOSES REDACTED]. 5. During an interview 07/11/19 at 10:00 AM with the MDS Coordinator (RN 12), she confirmed that [MEDICAL CONDITION] was currently listed as an active [DIAGNOSES REDACTED]. 6. RR of psychiatric consults dated 05/23/19, 01/12/17, 06/23/16, and 09/18/14 revealed no documentation of [MEDICAL CONDITION], hallucinations or paranoia. 7. On 07/11/19 08:28 AM during an interview with the Director of Nursing (DON), the discrepancy of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She stated when R85 first came to the facility, R85's records indicated [MEDICAL CONDITION] and she was on medication. All residents were rescreened in (YEAR) to identify those who needed the additional PASARR 11 pre-admission screening. R85 was identified as needing the screening, whic… | 2020-09-01 |
| 95 | 95 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2019-07-12 | 880 | E | 0 | 1 | 55H911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interviews, the facility failed to clearly identify and communicate the appropriate personal protective equipment (PPE) and precautions to be taken while performing their daily routine (i.e. housekeeping) or while providing care for residents that were on droplet precautions (actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions). One resident (R)33 of the five sampled did not receive enough education to understand why he was placed on droplet precautions or why he continued to be on them. Two other residents (R11 and R66) were also affected by the lack of knowledge/training related to the use of PPEs. The facility did not have a clearly defined policy or process in place to direct staff how to determine when the precautions were no longer needed, nor how to consistently implement transmission based precautions. Findings include: 1. The facility had residents on droplet precautions located on two different units (second and third floors). 2. On 07/09/19 at 09:00 AM, observed a laminated orange sign posted next to the doors of Room (Rm) 215, 216, 217 and 218. The sign read: Droplet Precautions . Respiratory protection: Mask required when working within 3 feet of patient (or when entering room). Check your hospital policy. At that time observed Rm 215, 217, and 218 were shared rooms with other residents. Rm 216 had separate entrances between them. There were droplet precaution signs posted over the bed of 215-3, 216-1, 217-3 and 218-2. 3. On 07/09/19 at 11:30 AM, during an interview with R33, he stated, I don't know why I have that sign (droplet precaution) up there. Asked if staff had informed him why he needed it (the precaution sign above his bed), and he replied, they just say because I have a cough. I've had a cough since I came in here. I'm afraid my family won't bring my grandkids in. 4. On 07/09… | 2020-09-01 |
| 96 | 96 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2018-08-28 | 686 | D | 0 | 1 | QVE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and review of facility policy, the facility failed to place a pillow between resident's feet to prevent pressure on her feet. This practice would put Resident (R) 73 at risk for developing a pressure ulcer (PU) on her feet. This deficient practice had the potential to affect the 4 residents identified by the facility to have pressure ulcers. Findings Include: On 08/22/18 at 10:06 AM during record review (RR) of R73's electronic medical record (EMR) noted R73 had documentation of recurrent open area on her right big toe dated 06/18/18. Reviewed R73's skin assessment dated [DATE] at 1304 found there was a PU that was unstageable that was acquired in facility. On 08/27/18 at 11:14 AM at R73's bedside, with licensed practical nurse (LPN)1, requested to see R73's right foot. LPN1 pulled back R73's blanket and sheet noted R73's right big toe was healed. LPN1 stated I will put a pillow when it was discovered that R73's feet were resting near each other, side by side, touching each other. Further RR found PU documentation on 08/14/18 stated PU was new but at bottom of documentation it stated under notes Wound RN assessed and seen-resolved. Record review (RR) found R73 coded for a stage 2 PU on her last annual Minimum Data Set ((MDS) dated [DATE]. It was noted on R73's care plan (CP) that she is at risk for skin breakdown due to vegetative state, incontinence and diabetes. R73's CP was in place for PU wound and foot care but no intervention listed to place a pillow between feet to prevent the development of a PU. On 08/27/18 at 11:55 AM interviewed Head Nurse (HN) 2 who stated staff should be placing a pillow between residents feet to prevent putting pressure on the foot/feet. Review of facility Skin Care and Pressure Injury Prevention policy stated D. Protection from Friction, Shear and Pressure 6. Use positioning wedges or pillows. 7. Suspend heels while in bed. Neither of these were done for R73 … | 2020-09-01 |
| 97 | 97 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2018-08-28 | 689 | D | 0 | 1 | QVE911 | Based on observations and staff interview, the facility failed to secure a storage room located on the third floor. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: 1. During an observation of the storage room (located on the third floor) on 08/21/18 at 10:13 AM, it was noted that the door (which contained a key pad lock mechanism) to enter the room was not locked and anyone could have entered freely. There was also no staff in the immediate vicinity to prevent anyone from entering the room. The room had three large trash containers, one floor buffing machine, a fan blower, two orange road cones, a wooden cabinet to store biohazards, and other miscellaneous items such as trash bags, and a floor sweeper. Access to this room may have put the safety of the residents and the public at risk for accident hazards. On 08/21/18 at 10:20 AM, after the above observation, the Administrator was questioned about the door. The Administrator stated that the door to that storage room should have been locked and secured. Then, upon further investigation of the door lock, it appeared that someone stuffed a napkin so that the door latch would not lock. The Administrator acknowledged the risk for accident hazards if the residents or the public had access to that room. | 2020-09-01 |
| 98 | 98 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2018-08-28 | 700 | D | 0 | 1 | QVE911 | Based on observation, record review, staff interview and facility policy review the facility failed to assess two residents (Resident (R) 34, R53) selected from the 40 resident sample for risk of entrapment from bed rails prior to installation and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails. This deficient practice has the potential to affect all residents at the facility who have bed rails and newly admitted residents. Findings Include: 1) On 08/21/18 at 08:30 AM observed R34's bed had bilateral upper quarter bed rails on the bed. On 08/27/18 at 03:20 PM record review (RR) of R34 hard copy medical chart and electronic medical record (EMR) did not find an assessment for risk of entrapment from bed rails and no informed consent to use bed rails. Inquired with head nurse (HN)2 on 2 Makai unit who confirmed that R34 did not have a risk assessment for bed rail use and no informed signed consent form to use bed rails. HN2 explained the facility had started a new process in (MONTH) (YEAR) that includes doing an assessment and also the bed rail consent form with each resident's next MDS assessment. 2) On 08/21/18 at 02:42 PM observed R53 had bilateral upper bilateral quarter side rails on her bed. On 08/27/18 at 04:14 PM RR found R53 is total dependence on staff for activities of daily living (ADLs) such as feeding, brushing teeth and bathing. R53 had upper bilateral quarter side rails (these were removed during survey) and is immobile in bed even though her care plan (CP) states that bed rails are used for bed mobility. Inquired with evening shift RN1 who confirmed that R53 could not use bed rails on her own. RN1 stated R53 can hold rolled wash cloths in her hands and can hold onto the bed rail if her hand is placed there by staff. RR of resident's hard medical chart found that R53 had a side rail evaluation dated 04/24/18 and it stated no side rail in use. RR noted R53 did not have a signed informed con… | 2020-09-01 |
| 99 | 99 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2018-08-28 | 880 | D | 0 | 1 | QVE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain infection control precautions for two residents out of 40 residents selected for review. Resident (R)8's open suction tubing with opposite end attached to suction canister was left on the bed side table. R73 had an open 0.9% Sodium Chloride (Normal Saline) container with an open date of 07/19 left at bedside with suction equipment was found on 08/28/18. The deficient practice had the potential to affect all residents who require suctioning at the facility. Findings Include: 1) On 08/21/18 at 08:30 AM observed R8's suction tube, leading from the suction canister, left on R8's bedside table and open end laying on top of the bedside table. On 08/21/18 at 09:45 AM inquired of HN2 if suction tube should be left open and on R8's bedside table and she concurred that suction tubing should not be left open on the bedside table. Later in the day, after lunch, HN2 stated that she changed out all of the suction attachments for all the residents on 2 Makai. 2) On 08/21/18 at 09:00 AM observed R73's bedside table with suction machine, tubing and normal saline. Noted that normal saline was open and dated 07/19. On 08/21/18 at 09:45 AM inquired of HN2 how long facility keeps open normal saline and she stated 24 hours. On 08/28/18 at 10:10 AM interviewed licensed practical nurse (LPN)2 who confirmed that she opened the 0.9% Sodium Chloride (Normal Saline) on 07/19 and stated that she used it one time for R73's [DEVICE] dressing change to cleanse the site, dated the bottle 07/19 and accidentally left it at bedside. LPN2 stated that it was her fault that she forgot to throw it out. LPN2 confirmed that they only use and keep the normal saline for 24 hours once it is opened. | 2020-09-01 |
| 100 | 100 | MALUHIA | 125009 | 1027 HALA DRIVE | HONOLULU | HI | 96817 | 2018-08-28 | 908 | E | 0 | 1 | QVE911 | Based on observation, staff interview, and review of facility policy, the facility failed to perform routine maintenance, based on manufacturer's recommendation, and failed to keep preventative maintenance records for two out of fourteen oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation and interview, on 08/21/18 at 2:30 PM, with staff RN3. RN3 stated the cleaning of all Oxygen Concentrator Filters were done on a weekly basis by the Certified Nursing Aides (CNA). However, during an interview with CNA1 on 08/21/18 at 2:31 PM, CNA1 was unable to cite when and how the cleaning of the Oxygen Concentrator Filter was performed. During an interview with the Central Supply Manager (CSM) on 08/21/18 at 3:03 PM, CSM stated that the floor CNAs were the ones to do the cleaning of the Oxygen Concentrator Filters. However, CSM acknowledged that the facility did not keep a record of the cleaning and there was no way to verify that the Oxygen Concentrator Filters were being cleaned as recommended by the manufacturer. During a review of facility policy pertaining to the cleaning and disinfection of equipment, it stated that the cleaning and filter changing of the Oxygen Concentrator's will be done based on manufacturer's recommendations. The facility failed to perform that. During an interview with Director of Nursing on 08/28/18 at 09:00 AM, it was acknowledged that the manufacturer's recommendations for their oxygen concentrators were not being followed. | 2020-09-01 |
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CREATE TABLE [cms_HI] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );